In the rehabilitative project of the patient with complex peripheral nerve lesion of the upper limb, several parameters condition the treatment choices: the age of the patient, mostly young, with high personal and social expectations, insertion or re-insertion in the field working, the compliance with the treatment that is presumed to be long – even 2- 5 years for proximal lesions – with sometimes alternating phases of recovery and without the possibility of prognosis neither in the medium nor in the long term just after trauma and surgery.
The final objective is obviously a functional hand: this means not only a hand that “moves” well (motor recovery) but above all a hand that “feels” (recovery of sensibility), and that from the aesthetic point of view and the trophism have satisfactory results; in fact, the hand is an important means of communication, second only to the face.
Therefore we identify the objectives of motor recovery in the power and dexterity and motor coordination in the various outlets through both classic work tools, for the recovery of passive and active joint ranges, both proprioceptive and ergotherapeutic, as close as possible to the activities of daily life and the specific work-sport context of that patient. To this end we also use computerized tools that offer visual feedback for the execution of movements that require various power-resistance-dexterity-alternating agonist / antagonists’ muscles.
The evaluation of motor recovery uses standardized tests such as the MRC ( M0-M5) scale for the evaluation of muscle strength, the Jamar grip and the Key-grip dynamometer for the pinches, as well as the neurophysiological monitoring with Conduction studies and EMG evaluation.
The primary objective in the recovery of sensitivity is to avoid the neglect, the “forgotten hand” or rejected, maintaining multiple afferences beguinning from simple passive mobilization, to facilities, to the search for the recovery of protective sensitivity (cold-hot and pain), and in succession , of the localization of touch, up to the discrimination of two fixed and mobile points. Also for the monitoring of sensitivity in addition to the clinic are performed standardized tests such as the Semmes-Weinstein with monofilaments for the tactile threshold of touch, the Dellon Disk-Criminator for the two fixed and mobile points, the Sensitive Conduction Study and the empirical recognition of shapes, textures and fabrics. Another computerized tool for the qualitative but above all quantitative evaluation of two-point discrimination is the QST (Quantitative Sensory Testing), evolution of Dellon’s Pressure Specified Sensory Device (PSSD). The work patterns, based on the results of the tests, follow progressions that increase the cortical integration of the stimuli.
In parallel, and not at all split from the rehabilitative program of sensitivity, there is the improvement of autonomic functions for the normalization of dystrophies of skin, attached, sweating, to control oedema through vasoregulation, for the simple care of the site of injury on the part of the patient so as to optimize the feeling and reintegration in the body schema: this with desensitization techniques, passive and active vascular exercises, that the patient performs during treatment and above all is trained to perform at home. In this case, in addition to the photographic documentation, instrumental monitoring takes place through the control of the presence / absence or symmetry, and amplitude and latency as well of the skin sympathetic responses in the study of the Vegetative or Autonomous Nervous System.
It is well known that the prognosis of these lesions is influenced by numerous factors including the lesion site, the time between the lesion and the surgery, the type of repair and the different anatomical structures involved, which interact with each other (vessels-tendons-nerves-joints-bone) in determining the priorities in the rehabilitation program, but this should never lose sight of the final goal as already stated above.
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