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The Optimization of Peripheral Nerve Recovery Using Cortical Reorganization Techniques
Bonnie Walbruch, OTR/L, CHT; Loree K. Kalliainen, MD
Regions Hospital, Saint Paul, MN

Functional outcomes of peripheral nerve repairs have not significantly improved over the past few decades. We propose that initiating an acute sensory re-education protocol using cortical reorganization shortly after nerve repair promotes faster and more complete sensory recovery than does standard treatment. The purpose of the protocol was to reprogram the somatosensory cortex by using alternative stimuli to preserve the cortical map. It included using all senses, sensory and motor imagery, selective surface anesthesia with tactile stimulation and imagery, and mirror therapy. The treatment program was advanced to include the traditional touch localization and object identification once there sense perception of returned. Throughout the treatment/recovery period, patients completed the Quick DASH questionnaire and sensation was assessed using static and moving 2-point discrimination, Semmes Weinstein Monofilaments and Moberg when appropriate. A retrospective search for peripheral nerve repairs done at our facility between 2008 and 2010 was performed. Patients who participated in the early sensory re-education program were identified. Eleven patients with acute wrist level nerve repairs were treated by hand therapists at our facility using early sensory cortical reorganization techniques. The nerves repaired included 3 radial sensory, 1 ulnar and 7 median. The sensory re-education program was begun within 2 weeks of the nerve repair. Patients were followed up to 47 weeks. The 2-point discrimination and Semmes Weinstein values suggest the outcomes are better than the traditional treatment outcomes as reported in the published literature. At the 4 month follow up half of our treated median nerve repairs had static 2-point discrimination of 7mm or less and 1 patient had 11 and 12mm 2PD. The remaining 2 patients could perceive touch only at both 4 and 11 month follow up. Semmes Weinstein Monofilament testing was purple or better in at least 1 digit of 9 of our patients with 4 patients being able to perceive the normal (green) filament. Our results compare favorably with Imai (1991) and Mavrogenis (2009) who, in separate studies, report static 2- point discrimination outcomes following median nerve repairs. Imai reported that only 4 of 22 patients regained 8-15mm of static 2-point discrimination with 2 year follow up. Maurogenis at 18 months had 18 of 20 patients with 7-15mm. Our retrospective study shows promise to the benefits of early sensory re-education but more study is needed to determine the speed and degree of improvement.


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