This document discusses technical aspects of microsurgical nerve repair. It begins with an overview of nerve structure and function, as well as types of nerve injuries. It then discusses factors that influence nerve repair outcomes such as delay to repair, tension at the repair site, and accurate fascicular alignment. Surgical techniques for nerve repair like epineural sutures and the use of fibrin glue are also described. Finally, the document covers post-operative management including splinting, nerve gliding exercises, monitoring recovery, and rehabilitation to maximize functional restoration.
Proprioceptive neuromuscular facilitation (PNF) is a stretching technique that can improve your range of motion. Many therapists use PNF to help people regain their range of motion after injury or surgery. However, it can also be used by athletes and dancers to improve their flexibility
Developing a Physical Therapy Marketing PlanDemandmart
The best way to start marketing your physical therapy business is to first develop a marketing plan so you know what steps you need to take to reach your goals. Marketing plans are not hard to develop but you need to know what you should include. Any small business can put together a marketing plan to work with. Take a look at our advice for what you should include in your marketing plan.
Stroke is defined as the most prominent and most fatal condition concerned with the human population with its prevalence greater in Asian and Indian population. There are varied reasons for the occurrence of stroke explained in the presentation.
Types of stroke and their consequences can also be summed up depending upon the type of lession, site of lesion and severity of lesion.
Proprioceptive neuromuscular facilitation (PNF) is a stretching technique that can improve your range of motion. Many therapists use PNF to help people regain their range of motion after injury or surgery. However, it can also be used by athletes and dancers to improve their flexibility
Developing a Physical Therapy Marketing PlanDemandmart
The best way to start marketing your physical therapy business is to first develop a marketing plan so you know what steps you need to take to reach your goals. Marketing plans are not hard to develop but you need to know what you should include. Any small business can put together a marketing plan to work with. Take a look at our advice for what you should include in your marketing plan.
Stroke is defined as the most prominent and most fatal condition concerned with the human population with its prevalence greater in Asian and Indian population. There are varied reasons for the occurrence of stroke explained in the presentation.
Types of stroke and their consequences can also be summed up depending upon the type of lession, site of lesion and severity of lesion.
This is a simple and easy to follow powerpoint presentation I had completed for an ICT class at my college. Its purpose was to showcase a basic knowledge of a topic within our field of study, as well as, create a presentation with animation and transitions to prove understanding of how to optimize presentation effectiveness.
Pain pathway gate control theory
Pain management
An unpleasant emotional experience usually initiated by noxious stimulus and transmitted over a specialized neural network to CNS where it is interpreted as such.
1. Exteroceptors: arising from receptors from skin & mucosa. sensed at conscious level
E.g. Merkel corpuscles : Tactile receptors.
Free Nerve ending :Perceive superficial pain.
2. Proprioceptors : From musculoskeletal structures.
The presence , positions & movement of body. below conscious levels.
E.g. 1) Muscle spindles : Skeletal muscle fibers. Mechanoreceptors.
2) Free nerve ending : Perceive deep somatic pain & other sensations.
3. Interoceptors : From viscera of body below conscious level.
E.g. Pacinian corpuscles : perception of touch-pressure.
Free nerve ending : Perceive visceral pain & other sensations.
“The ability of neurons to change their function, chemical profile or structure is referred to as neuroplasticity.”
Neuroplasticity includes :
- Habituation
- Learning & memory
- Cellular recovery after injury
Neurological physiotherapy is the treatment of individuals who have neurological impairments.
for example Traumatic Brain Injury or Stroke; Multiple Sclerosis, Spinal Cord Injury and Parkinson's disease.
At the end of the lecture the participant will be able to:
1. Understand the intracellular and extracellular processes that occur after a nerve injury, including Wallerian degeneration
2. Describe the classification of peripheral nerve injuries in relation to management and prognosis
3. Understand the physiology of nerve regeneration and its implication in modern nerve surgery including allografts and nerve conduits.
4. Describe the effects of peripheral nerve injury on distal structures (Motor and sensory end organs)
Commonly used Manual therapy technique by Physiotherapists,Osteopaths .useful in treating many of the soft tissue ailments and also a very useful tool in Sports physiotherapy.This deals with the basic concept of mayofascial release technique and its types ,indications ,basic concept of fascia,its functions.
This is a simple and easy to follow powerpoint presentation I had completed for an ICT class at my college. Its purpose was to showcase a basic knowledge of a topic within our field of study, as well as, create a presentation with animation and transitions to prove understanding of how to optimize presentation effectiveness.
Pain pathway gate control theory
Pain management
An unpleasant emotional experience usually initiated by noxious stimulus and transmitted over a specialized neural network to CNS where it is interpreted as such.
1. Exteroceptors: arising from receptors from skin & mucosa. sensed at conscious level
E.g. Merkel corpuscles : Tactile receptors.
Free Nerve ending :Perceive superficial pain.
2. Proprioceptors : From musculoskeletal structures.
The presence , positions & movement of body. below conscious levels.
E.g. 1) Muscle spindles : Skeletal muscle fibers. Mechanoreceptors.
2) Free nerve ending : Perceive deep somatic pain & other sensations.
3. Interoceptors : From viscera of body below conscious level.
E.g. Pacinian corpuscles : perception of touch-pressure.
Free nerve ending : Perceive visceral pain & other sensations.
“The ability of neurons to change their function, chemical profile or structure is referred to as neuroplasticity.”
Neuroplasticity includes :
- Habituation
- Learning & memory
- Cellular recovery after injury
Neurological physiotherapy is the treatment of individuals who have neurological impairments.
for example Traumatic Brain Injury or Stroke; Multiple Sclerosis, Spinal Cord Injury and Parkinson's disease.
At the end of the lecture the participant will be able to:
1. Understand the intracellular and extracellular processes that occur after a nerve injury, including Wallerian degeneration
2. Describe the classification of peripheral nerve injuries in relation to management and prognosis
3. Understand the physiology of nerve regeneration and its implication in modern nerve surgery including allografts and nerve conduits.
4. Describe the effects of peripheral nerve injury on distal structures (Motor and sensory end organs)
Commonly used Manual therapy technique by Physiotherapists,Osteopaths .useful in treating many of the soft tissue ailments and also a very useful tool in Sports physiotherapy.This deals with the basic concept of mayofascial release technique and its types ,indications ,basic concept of fascia,its functions.
Nervous System -Autonomic Nervous System-Neurons -Ganglia - Nerves Copy.Home
The nervous system is the body's communication network, coordinating and regulating all bodily functions. Comprising the central nervous system (CNS) and peripheral nervous system (PNS), it consists of neurons, specialized cells transmitting electrical and chemical signals. The CNS, consisting of the brain and spinal cord, interprets and processes information. The PNS extends from the CNS, transmitting signals between the brain, spinal cord, and the rest of the body. Sensory neurons detect stimuli, while motor neurons control muscle movement. This intricate system enables sensory perception, voluntary and involuntary actions, and regulates bodily processes, ensuring homeostasis and facilitating responses to the environment.
Nervous System -Autonomic Nervous System-Neurons -Ganglia - Nerves Copy.Home
The nervous system is the body's communication network, coordinating and regulating all bodily functions. Comprising the central nervous system (CNS) and peripheral nervous system (PNS), it consists of neurons, specialized cells transmitting electrical and chemical signals. The CNS, consisting of the brain and spinal cord, interprets and processes information. The PNS extends from the CNS, transmitting signals between the brain, spinal cord, and the rest of the body. Sensory neurons detect stimuli, while motor neurons control muscle movement. This intricate system enables sensory perception, voluntary and involuntary actions, and regulates bodily processes, ensuring homeostasis and facilitating responses to the environment.
AI in Healthcare APU Using AI in Healthcare for clinical Application research...Vaikunthan Rajaratnam
Discover how generative AI is transforming the face of healthcare. From accelerating drug discovery to empowering personalized treatment, this technology is reshaping the way we deliver and experience care."
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
A scoping review of the literature, its impact and challenges in healthcare, and a personal experience of its application in practice, teaching, and research.
COMPARATIVE ANALYSIS OF CHATGPT-4 AND CO-PILOT IN CLINICAL EDUCATION: INSIGHT...Vaikunthan Rajaratnam
This research investigates the potential of two advanced AI language models, ChatGPT-4 and Co-Pilot, to transform medical education through clinical scenario generation. Focusing on scenarios for Diabetic Neuropathy, Acute Myocardial Infarction, and Pediatric Asthma, the study compares the accuracy, depth, and practical teaching utility of content generated by each platform. A panel of medical experts assessed the AI-generated scenarios, and healthcare professionals provided feedback on their perceived usefulness in educational settings. Results suggest that ChatGPT-4 excels in providing structured foundational knowledge, while Co-Pilot offers greater depth through realistic patient narratives and a focus on holistic care. This indicates that both platforms have value, with their suitability depending on specific educational objectives – ChatGPT-4 aligns better with introductory learning, and Co-Pilot better serves advanced applications emphasizing practical clinical reasoning.
This workshop is a comprehensive introduction to the application of Generative AI in healthcare. It provides healthcare professionals, educators, and researchers with practical experience in using Generative AI for data analysis, predictive modeling, and personalized treatment planning. The workshop also explores the use of Generative AI in medical education and research. No prior AI experience is required, making this a unique opportunity to learn about the latest advancements in Generative AI and its healthcare applications.
This workshop will empower healthcare professionals with the knowledge and skills to leverage artificial intelligence (AI) in their practice. It aims to bridge the gap between cutting-edge technology and everyday clinical, research, and educational practice. The platforms covered in the workshop include Elicit.org, Scholarcy.com, Typeset.io, ChatGPT, Botpress.com, InVideo.io, and Genie.io.
The objectives of this specialised workshop are to:
• Explore the core principles of AI, emphasising its applications and significance in modern healthcare.
• Examine the role of AI in enhancing clinical judgment and patient management, with live demonstrations of relevant tools.
• Uncover the potential of AI in revolutionising teaching and learning experiences for healthcare professionals and students.
• Illustrate the integration of AI in healthcare research, focusing on tasks such as literature review, data analytics, and manuscript development.
• Provide a hands-on experience with various AI platforms tailored to healthcare professionals' unique needs and demands
A one day workshop on the use of AI in Healthcare for practice, teaching and research.
The Resource Material for the "AI in Healthcare" workshop serves as an essential guide for healthcare professionals who aim to harness the transformative power of Artificial Intelligence (AI) in clinical practice, medical education, and research. Developed under the expertise of Dr Vaikunthan Rajaratnam, this comprehensive package is designed to complement the workshop, providing both foundational knowledge and practical tools for immediate application.
The slide deck for the "AI for Learning Design" workshop, hosted at Asia Pacific University, serves as a comprehensive guide to integrating Artificial Intelligence into educational settings. Designed to empower educators and instructional designers, the presentation offers actionable strategies for curriculum integration, insights into personalized learning through AI, and a deep dive into the ethical considerations that accompany AI adoption in education. The deck is structured to facilitate an interactive and engaging workshop experience, featuring real-world examples, hands-on activities, and spaces for thought-provoking discussions. Don't miss this invaluable resource for transforming your teaching practices and enhancing educational impact through AI.
empowereing practice in healthcare with generative AI. How to use vairous AI tools to enhance and empowere healthc are practice inlcuidng teaching and research
Academic writing is the backbone of scholarly communication and is vital in knowledge dissemination. However, it can often be challenging and time-consuming, requiring meticulous attention to detail and adherence to established conventions. This is where AI comes into play, offering innovative solutions to streamline and enhance the writing process.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
Tips in micro neural repairs
1. Technical aspects of micro surgical repair
Andrew Yam
At the end of the lecture the participant will be able to:
1. List and describe the types of peripheral nerve repair
2. Describe in detail the surgical techniques of repair
3. Identify possible difficulties in repair and strategies to overcome them
Postoperative management of nerve repair
Andrew Yam
At the end of the lecture the participant will be able to:
1. Describe the principles of splinting in nerve repair
2. Describe and perform qualitative assessment of nerve recovery
3. Understand the role of the brain in nerve recovery and rehabilitation
4. Develop a management strategy for sensory and motor rehabilitation post repair
5. Identify poor outcomes early and describe principles of management
2. Microsurgical Nerve Repair :
Technical Aspects
Dr Andrew Yam
Consultant Hand Surgeon
Director of Peripheral Nerve and Paralytic Upper Limb Service
Singapore General Hospital
3. Nerve Structure and Function
Nerves are the “biological
electrical wiring” connecting the
upper limb to the brain
4. NEURON - basic
functional unit
MOTOR NEURON SENSORY NEURON
CELL BODY
-In spinal cord (motor
neuron) or dorsal root
ganglion (sensory
neuron)
-Communicates with
neurons from the
brain centres
-Produces proteins
for nerve function
AXON
-in the nerve trunks
-Extension to the
end-organs
5. Axons are arranged in
FASCICLES
3 layers of
CONNECTIVE
TISSUE
-Endoneurium
-Perineurium
-Epineurium
BLOOD VESSELS
reach nerve via the
mesoneurium
NERVI NERVORUM
supply sensation to
nerve trunk
PAIN/TENDERNESS
GLIDING PLANE
between nerve trunk
and surrounding
tissues
Nerve Trunk
7. Sunderland, 1951
NeurapraxiaNeurapraxia
AxonotmesisAxonotmesis
NeurotmesisNeurotmesis
Non-degenerative
Degenerative
Seddon, 1943 Birch, 1998
TYPES OF NERVE INJURY
Wallerian degeneration
distal to injury
Recovery by regeneration
from proximal stump at 1-2
mm/day
(Tinel’s sign +ve,Tinel’s sign +ve,
sequential recoverysequential recovery)
Variable recovery, neverVariable recovery, never
100%100%
Neurotmesis (Type 4, 5)Neurotmesis (Type 4, 5)
WILL NOT RECOVERWILL NOT RECOVER
spontaneous completespontaneous complete
recovery, usually within 2recovery, usually within 2
monthsmonths
8. Factors influencing the
outcome of nerve injuries
• Non-technical factors
– Age
– specific nerve injured
– level of injury
– nature of injury
– delay to repairdelay to repair
• Technical factorsTechnical factors
– TensionTension
– Accurate alignmentAccurate alignment
– Repair techniqueRepair technique
– Post-repairPost-repair
rehabilitationrehabilitation
9. Delay from injury to presentation
Longer delay
to repair
→ more cell
body death
→ less
regeneration
→ worse
outcome
Wiberg et al
10. Delay to repair
• loss of 1% of neural function for each
week of delay beyond the 3rd week
Time limit for
nerve repair -
18 months
11. Wallerian Degeneration and Regeneration
Distal to injury – degeneration
(up to 2 weeks to complete)
Cell body and axon proximal to injury
- Regeneration 1-2 mm/day after
degeneration complete
12. • Nerve healing across a gap =
– Axonal regeneration (repair of the nerve cell)
• Axonal sprouting and growth cones
• Branching and competition for targets
• Guidance and misdirection
+
– Local wound healing (reconstitution of the nerve fiber)
• “Intrinsic”
– Proliferation of endothelial cells, fibroblasts, Schwann cells from
the stump epineurium fascicles
• “Extrinsic”
– Inflammation and migration of fibroblasts from surrounding
tissues scar
13. Nerve Repair
The goal of nerve repair is to decrease and
enclose the gap by approximating the nerve
ends, allowing primary healing with
minimal scarring:
A favourable environment for the regenerating
nerve axon.
14. TENSION
• TENSION compromised intraneural
vascularity poor healing, scarring
• Critical distance = 1.5cm to 7cm depending on
the nerve and location
• Too much tension
– >10% stretching
– Excessive postural manipulation
– Nerve ends cannot be approximated with a single 6-0
nylon and repaired with 8-0 or smaller suture and
withstand gentle ROM
16. Bridging the gap
NERVE GRAFT
-Autograft
-Allograft
-Tissue engineered
CONDUIT
-vein
-synthetic (silicon, polylactide, etc)
17. Fascicular alignment
• Use a microscope for accurate repair
• Match the motor and sensory
fascicles correctly
– Align vessels on epineurium
– Topography of cut ends match
fascicular groups by shape and size
– Knowledge of cross-sectional nerve
anatomy
– Histochemical staining of sections
from nerve ends
19. Technical tips
• Trim back adventitia
• Catch both external and
internal epineurium (epineurial
repair) – aligns fascicle
• Double throw and square
knots
– Appose ends lightly without
bunching fascicles
• As few sutures as possible
– appose all major fascicle
groups and entire
circumference evenly
20. Suture size for nerve repair
Large nerve trunks (epineurial repair)
Spinal nerves, brachial plexus trunks, ulnar nerve, median
nerve, etc
8-0
7-0 or 6-0 acceptable
Cutaneous nerves of limb
Medial antebrachial cutaneous nerve, superficial radial nerve
(in forearm), etc
9-0
Common digital nerves in palm
Grouped fascicular repair of nerve trunks
9-0
Proper digital nerves in fingers, terminal
branches of motor nerves, nerve transfers
10-0
Cabled nerve grafts 10-0
21. Fibrin clot glue
• Use with sutures or on its own
• Less sutures = faster repair, less fibrosis
• Seals gaps between apposed epineurial ends
• Decrease nerve adhesions at repair site
22. Microsurgical Nerve Repair:
Post-repair Rehabilitation and
Monitoring
Reconstructive surgery only creates
factors favouring successful
rehabilitation and functional recovery:
it is only the first of many steps
23. Post-nerve repair
• Protect the repair!
– SPLINTSPLINT for 3-6 weeks in position of minimal tension
– Block movements that stretch nerve, allow those that slacken
nerve
• Prevent adhesions
– NERVE GLIDINGNERVE GLIDING exercises during and after period of splinting
• Monitor for recovery
• Formal rehabilitation programme
24. Monitoring regeneration and
recovery
• Calculate expected time of recovery
– 2-4 weeks lag time from repair to start of axonal regeneration
– Axonal regeneration at 1mm/day (1 inch/month)
• Monitor signs of recovery
– Distal progression of Tinel’s sign
– Sequential recovery of muscles from proximal to distal
– Recovery of sweating and sensation
• Watch for signs of failure (complete or partial)
– Tinel’s fails to progress
– Lack of sequential recovery at expected times
25. Impact of peripheral nerve injuries
of the upper limb
• Sensory loss
• Motor loss
• Autonomic loss
• Pain
SEVERE LOSS OF ABILITY TO FUNCTION IN DAILY ACTIVITIES AND VOCATION
“The hand is the visible part of
the brain” – Immanuel Kant
26. GOALS OF RECONSTRUCTION AND REHABILITATION:
MAXIMUM FUNCTIONAL RESTORATIONMAXIMUM FUNCTIONAL RESTORATION
USEFUL INDEPENDENT FUNCTIONUSEFUL INDEPENDENT FUNCTION
SOCIAL REINTEGRATIONSOCIAL REINTEGRATION
ACCEPTANCE OF “NEW NORMAL”ACCEPTANCE OF “NEW NORMAL”
Restoration of “NORMAL” function is seldom possible after severe nerve injury
Psychosocial impact
Loss of independenceLoss of independence
Loss of job/financial viabilityLoss of job/financial viability
Depression and helplessnessDepression and helplessness
27. Stages of Recovery
Stage IStage I
DegenerationDegeneration
(First 2-3 weeks)(First 2-3 weeks)
Wallerian degenerationWallerian degeneration
Loss of nerve functionLoss of nerve function
Cortical rearrangement startsCortical rearrangement starts
28. Stages of Recovery
Stage I
Degeneration
(First 2-3 weeks)
Wallerian degeneration
Loss of nerve function
Cortical rearrangement starts
Stage IIStage II
RegenerationRegeneration
(2-18 months depending on(2-18 months depending on
distance to target organ)distance to target organ)
Axonal regeneration after successfulAxonal regeneration after successful
repairrepair
Chronic denervation changes, end-organChronic denervation changes, end-organ
atrophyatrophy
Decreased motor and sensory corticalDecreased motor and sensory cortical
representationrepresentation
29. Stages of Recovery
Stage I
Degeneration
(First 2-3 weeks)
Wallerian degeneration
Loss of nerve function
Cortical rearrangement starts
Stage II
Regeneration
(2-18 months depending on distance to
target organ)
Axonal regeneration after successful repair
Chronic denervation changes, end-organ atrophy
Decreased motor and sensory cortical representation
Stage III
Reinnervation and maturation
(Up to 5 years)
Function returns but impaired due to
denervation atrophy, immature and decreased
axons and cortical representation
Increasing function with maturation and
cortical reorganisation
30. Rehabilitation after Peripheral Nerve Injury
Surgical Therapy
STAGE ISTAGE I
(Degenerative stage)(Degenerative stage)
DiagnosisDiagnosis
Assess severityAssess severity
Nerve repair/reconNerve repair/recon
Sensory and motor assessmentSensory and motor assessment
Prevent complications ofPrevent complications of
denervationdenervation
Sensory re-educationSensory re-education
Pain controlPain control
32. Abnormal joint postures due to imbalanced forces across
joints joint contracturesjoint contractures
Myostatic contractureMyostatic contracture
Tendon adhesionsTendon adhesions
OedemaOedema
-Dependent limb
-Loss of muscle pump
-Loss of sympathetic tone
Stiffness
33. PATIENTS TEND TO NEGLECT OR AVOID MOVING AND TOUCHING THE
DENERVATED LIMB
Median and ulnar nerve – MCPJ extension and PIPJ flexion contractures
Radial nerve – flexion contractures
Brachial plexus – shoulder, elbow, wrist, finger contractures
34. Joint stiffness is a contraindication for tendon transfers
Reinnervated muscles will not overcome stiffness
ALL JOINTS MUST BE KEPT SUPPLE IN
ANTICIPATION OF FUNCTIONAL RECOVERY BY
REINNERVATION OR MUSCLE TRANSFER
35. Management of joints post nerve injury
Passive mobilization through full range as early as possible
Patient education and compliance – prevent neglect
Splinting with caution in insensate hands
No heat therapy in insensate hands
Surgical release as necessary
36. Secondary injury and infection
Insensate limbs prone to serious injury - no withdrawal
reflex
Paralyzed limbs cannot be moved out of danger
Neuropathic ulcers
Burns
Neglected cuts
Severe infection with
delayed treatment
37. Preventing secondary injury and infection
Awareness of danger of insensate limb
Avoid exposure to hot, cold or sharp objects
Frequent inspection for injury
Keep flail limbs in sling
Avoid prolonged pressure including splints
38. Neuropathic Pain
• Most major nerve
injuries
• Up to 80% of brachial
plexus avulsion injuries
NEUROPATHIC PAIN MAY BE THE
MOST CRIPPLING ASPECT OF
NERVE INJURY
CRPS Type II
Avulsion/deafferentation pain
Neurostenalgia
Abnormal perception of stimuli –
allodynia, dysaesthesia
39. Pain management
• Pharmacological
• Physical
• Behavioural
• Psychological
• Surgical
AGGRESSIVE EARLY MULTI-MODALITY TREATMENT OF NEUROPATHIC
PAIN IMPORTANT TO DECREASE RISK OF DEVELOPING CHRONIC PAIN
SYNDROME
40. Physical Techniques of Pain
Control
• Desensitisation
• TENS (transcutaneous electrical
stimulation)
• Physical activity
AIM TO WEAN PATIENT OFF PAIN MEDICATION AND “WORK WITH THE PAIN”
41. Desensitisation
• Gate-control theory Melzack
• Non-painful stimulus
– To border of hyperaesthetic
area
– To territory of other nerves in
same dermatome
– To adjacent dermatome
• Gradual increase in intensity
of stimulus
42. Sensory Re-education (Early)
• CORTICAL PLASTICITY
• Decreased afferent transmission to cortex decreased cortical
representation of denervated area
• Early (immediate) re-education to maintain cortical representation
• Substitute touch sense with visual or auditory
Rosen B, Lundborg G. Enhanced sensory recovery after median nerve repair using cortical audio-tactile interaction. A
randomised multicentre study. JHSE 2007
Rosen B, Lundborg G. Sensory reeducation after nerve repair: aspects of timing. Handchir Mikrochir Plast Chir 2004
43. Rehabilitation after Peripheral Nerve Injury
Surgical Therapy
STAGE ISTAGE I
(Degenerative stage)(Degenerative stage)
DiagnosisDiagnosis
Assess severityAssess severity
Nerve repair/reconNerve repair/recon
Prevent complications of denervationPrevent complications of denervation
Sensory re-educationSensory re-education
Pain managementPain management
STAGE IISTAGE II
(Regeneration)(Regeneration)
Manage contractures,Manage contractures,
adhesions and otheradhesions and other
complications ofcomplications of
denervationdenervation
Monitor recoveryMonitor recovery
(advancing Tinel’s sign)(advancing Tinel’s sign)
Adaptive techniquesAdaptive techniques
Assistive devicesAssistive devices
Pain managementPain management
Strengthen and isolateStrengthen and isolate
donor musclesdonor muscles
44. PERIPHERAL NERVE INJURIES RARELY INCAPACITATE
COMPLETELY!
Augmenting existing function
• Assistive devices and
coping strategies
• Avoid inactivity and
reinforcement of
“helplessness”
45. Assistive devices
Training uninjured limb to compensate
Train to do things differently to compensate
Change of mindset - motivational talks, acceptance
of limitation, hope for recovery, employment
Methods to augment existing function
ENCOURAGE USE OF THE INJURED LIMB AS MUCH AS POSSIBLE
48. Strengthening and Isolating Donor Muscles
All potential donor muscles for transfer identified
Physical exercises to increase strength
Visualisation of new function while activating donor
muscle
Physical activity decreases neuropathic pain and
increases sense of well-being
EARLY TRAINING OF DONOR MUSCLES FACILITATES
RE-EDUCATION AFTER TRANSFER
49. Rehabilitation after Peripheral Nerve Injury
Surgical Therapy
STAGE ISTAGE I
(Degenerative stage)(Degenerative stage)
DiagnosisDiagnosis
Assess severityAssess severity
Nerve repair/reconNerve repair/recon
Prevent complications of denervationPrevent complications of denervation
Sensory re-educationSensory re-education
DesensitisationDesensitisation
STAGE IISTAGE II
(Regeneration)(Regeneration)
Manage contractures, adhesions and otherManage contractures, adhesions and other
complications of denervationcomplications of denervation
Monitor recovery (advancing Tinel’s sign)Monitor recovery (advancing Tinel’s sign)
Adaptive techniquesAdaptive techniques
Assistive devicesAssistive devices
DesensitisationDesensitisation
Strengthen and isolate donor musclesStrengthen and isolate donor muscles
Stage IIIStage III
(Post-reinnervation(Post-reinnervation
oror
reconstruction)reconstruction)
Tendon transfersTendon transfers
Functioning free muscleFunctioning free muscle
Protected mobilisationProtected mobilisation
Re-training of transferredRe-training of transferred
nerve or musclenerve or muscle
StrengtheningStrengthening
Sensory re-educationSensory re-education
50. Graduated strengthening exercises
- gravity eliminated exercises
- resistance exercises
- functional use and work hardening
Neuromuscular electrical stimulation
Biofeedback
Muscle strengthening and training
53. Neuromuscular Electrical Stimulation
(NMES)
• Surface electrodes stimulate
reinnervated muscle end
plates augmenting active
contraction
• High intensity, short
duration
• Beware of muscle fatigue
and injury
54. Biofeedback
• Surface electrode EMGs
• Visual/auditory feedback
– Increase contraction of
agonist muscles
– Decrease contraction of
antagonists
• Useful for managing co-
contractions and training
tendon/muscle transfers
55. Summary
• Intensive structured rehabilitation program is essential to achieve
good functional results after nerve injury and reconstruction
• Rehabilitation starts immediately post-injury to minimize cortical
reorganization and encourage ongoing use of the denervated upper
limb
• Program tailored to different stages of recovery
• Patient motivation is essential until reinnervation and maturation (up
to 2 YEARS for higher lesions, BPI)
• Pain management is vital – the patient will not use a painful limb
• Early return to function while accepting limitations and
learning to adapt is the goal
Editor's Notes
The cortical representation of the hand takes up a disproportionately large area of the brain both in the motor and sensory cortices, such that the hand has been called the visible part of the brain.
The connection between the hand and brain is disrupted by injuries to the peripheral nerves, which are the broadband cables bringing sensory information to the brain and motor commands from the brain to the hand. In addition, severe and intractable pain may arise due to the nerve injury, and autonomic functions are disrupted, resulting in trophic changes.
Peripheral nerve injuries of the upper limb thus result in a severe loss of ability to function in daily activities and vocation.
While the physical effects of nerve injuries are obvious, we often overlook the psychosocial effects.
Loss of function leads to loss of independence, loss of job and financial viability, and ultimately loss of self-esteem, depression and helplessness.
While restoration of normal function is seldom possible after severe nerve injury, it is certainly possible in most cases to reconstruct and rehabilitate the patient to a useful, independent level of function, allowing reintegration into society.
To effectively reconstruct and rehabilitate a patient with nerve injuries, it is necessary to understand the biology of nerve injuries and recovery.
The biological process can be divided into three stages, and a rehabilitation programme designed around each stage.
The first stage is DEGENERATION. The injured nerve undergoes wallerian degeneration over the first 2-3 weeks. Loss of nerve function is evident, but what is not so obvious is that changes start to occur in the brain as well. The denervated area’s representation in the cortex starts to shrink, and synapses start to disappear.
The second stage is REGENERATION. In an axonotmesis, axonal regeneration occurs at a rate of 1-2 mm a day from the proximal end of the injured nerve and moves towards the target organs. In a neurotmesis, this cannot occur because of the gap between the ends, and a neuroma forms. A successful nerve repair that bridges the gap is required to allow regeneration.
The target organ atrophies and displays chronic and progressive denervation changes until it is reinnervated by the regenerating axons.
In the brain, the sensory and motor areas representing the denervated area becomes progressively smaller.
The third stage, REINNERVATION AND MATURATION begins once the regenerating axons reach the target organ. The previous denervation changes are reversed. How much function returns after successful reinnervation depends on the duration of denervation.
Initially, the function is impaired by atrophy of the end-organ, immaturity and decreased axon numbers, and decreased and deranged cortical representation. Function can continue to improve for several years, with ongoing maturation of the reinnervated organ, regenerated axons and cortical reorganisation.
Each stage presents a different challenge to the reconstructive surgeon and the therapist.
In the first stage, the surgeon must diagnose the location, nature and severity of the lesion, and do neurolysis, nerve repair, grafting or nerve transfer as appropriate.
The therapist must accurately assess sensory and motor function to determine the functional loss and remaining function. The patient must be educated to avoid complications of denervation. Sensory re-education is started to minimise the impact of cortical reorganisation, and neuropathic pain must be controlled.
Complications of denervation are stiffness, injury and infection, and neuropathic pain.
Denervated limbs easily become stiff.
Prolonged abnormal joint postures due to imbalanced forces across the joints result in joint contractures.
Myostatic contractures occur in unopposed muscles that are continually contracted.
Tendon adhesions and dependent limb oedema also contribute to stiffness.
Typically, the MCPJs become stiff in extension and the PIPJs stiff in flexion in median and ulnar nerve injuries, while in radial nerve injuries, flexion contractures occur.
In brachial plexus injuries, shoulder, elbow, wrist and finger stiffness are common.
The main cause of stiffness is the patient’s tendency to neglect or avoid moving and touching the denervated limb.
As stiffness prevents successful tendon transfer and prevents reinnervated muscle from moving the joints, it is critical to keep all joints supple in anticipation of functional recovery either by reinnervation or by muscle transfer.
The patient, working with the therapist, has the main responsibility.
Passive mobilisation through the full range is taught as soon as it is safe to do so, pending healing of concomitant injuries to bone and tendon.
The patient is taught to perform the exercises at least 20 times every hour, and monitored weekly for compliance.
Splinting is used with caution in insensate hands, as pressure ulcers may develop.
Heat therapy is contraindicated in denervated hands.
If contractures develop that are resistant to stretching and splinting, surgical release may be needed.
Another problem with denervated limbs is injury and infection.
Insensate limbs are prone to serious injury as there is no withdrawal reflex. Paralyzed limbs cannot be moved out of danger.
Denervated skin is soft and dry and does not heal well.
The classic example is the patient with leprosy, who develops neuropathic ulcers, severe burns, neglected cuts ultimately resulting in severe infection that is not noticed and treated late, resulting in loss of the extremity.
It is important to educate the patient on the dangers of the insensate limb, to avoid hot, cold or sharp objects, to inspect frequently for injury, and to keep flail limbs in a sling close to the body. Prolonged pressure must be avoided, including from splints and tools.
Neuropathic pain, while not so common, is probably the most crippling aspect of nerve injury. It is most common in avulsion injuries of the plexus, but may occur in traction lesions, partial nerve lacerations, and with neuroma formation. The pain is characteristic – stabbing, shooting, pins and needles, “numb”, burning, throbbing, and electric-shocks.
Managing this pain is crucial in restoring the patient to useful function, as the patient will not use the limb even if muscle power and sensation is restored if the pain is too severe.
Multi-modal treatment must be started early and aggressively. This involves drugs like pregabalin, physical techniques, behavioural techniques, and psychological techniques. Surgical neurolysis may be effective in some cases.
In some centres like the Peripheral Nerve Injuries Unit at the Royal National Orthopaedic Hospital in Stanmore, patients with severe neuropathic pain are admitted for a week to the rehabilitation ward for intensive pain management involving all modalities, especially physical therapy.
The goal of multi-modal pain therapy is to wean the patient off their pain medication and teach them to work and live with a bearable level of pain.
Methods used include desensitisation, transcutaneous electrical stimulation, and guided physical activity.
Encouraging the patient to engage in physical activity involving the injured limb as much as possible, helps distract from the pain and gives the patient confidence in using the limb despite pain.
Desensitisation and TENS works via the gate-control theory of pain. A non-painful stimulus is applied to the border of the hypersensitive area, or to the territory of other nerves in a same dermatome or an adjacent dermatome. This sensory signal travels by fast nerve fibres and inhibits pain signals travelling in slower fibers. The stimulus is gradually increased in the hypersensitive area until the patient is able to tolerate pressure compatible with daily contact when using the limb.
Early sensory re-education is advocated by Rosen and Lundborg. They found that cortical plasticity results in reorganisation of the cortical representation of the denervated limb soon after the nerve injury. Early re-education using the eyes or ears to substitute for the sense of touch, and “mirror therapy” helps to maintain the cortical representation of the denervated limb. This facilitates return of function once reinnervation occurs.
In the second stage, the surgeon must manage contractures, adhesions, and other complications of denervation while monitoring for signs of recovery.
The therapist should help the patient to function independently via adaptive techniques and assistive devices. Pain management continues. Donor muscles should be trained and strengthened in anticipation of possible transfers.
It is important to restore the patient to independent function early, despite the limitations imposed by the denervated limb. Peripheral nerve injuries rarely incapacitate completely. The exception is a bilateral total brachial plexus injury, which is extremely rare. Attitudes are the real disability: the attitudes of the patient, their family and their employers. Each should be engaged to help the patient avoid inactivity and reinforcement of helplessness.
Numerous methods can be used to augment any existing function. The goal is always to encourage the patient to use the denervated limb as much as possible and to function independently.
Some assistive devices we commonly use are the dynamic finger and wrist extension splint for radial nerve, opposition strap for median nerve and anti-claw splint for ulnar nerve
More complex devices are also used for brachial plexus injuries, such as a locked elbow splint for upper type BPI to position the functioning hand, a flail arm splint in total BPI to allow some control of the limb using the contralateral scapulothoracic movements, and a gauntlet that can be fitted with various attachments to allow the limb to assist in bimanual tasks. These are cumbersome and difficult to fit and train. However, a motivated patient will find them useful. At the Peripheral Nerve Injuries unit in Stanmore, two patients with BPI with poor recovery are employed in the orthotics department and work using these devices.
Strengthening and isolating donor muscles helps facilitate re-education after transfer, and also decreases neuropathic pain by encouraging the patient to use the limb.
In the final stage, reinnervation or lack of reinnervation is seen. If function is not adequate, tendon and muscle transfers may be useful.
Protected mobilisation is started after the transfers, followed by re-training and strengthening.
If nerve transfers were done in the first stage, then these must be trained to perform their new function.
Sensory re-education now aims to improve tactile gnosis.
Muscle strengthening and training is done by graduated strengthening exercises, aided by neuromuscular electrical stimulation and biofeedback
Gravity eliminated exercises are started once M2 power returns. Slings and low friction devices are used to allow patient to move the limb actively. Exercising in a swimming pool or hydrotherapy pool is also useful.
Resistance training starts with M3 power, followed by work hardening
Neuromuscular electrical stimulation helps to augment muscle contractions by delivering high intensity, short duration bursts of current to the motor end plates. It is important not to overuse this, as muscle fatigue and injury can occur it contractions are too strong or frequent.
Biofeedback provides useful visual or auditory feedback indicating when the agonist and antagonist muscles are activated. This can help the patient to increase contraction of agonists and decrease those of antagonists. It is most useful for managing co-contractions and training tendon or muscle transfers.