Direct electrical stimulation on the injured ulnar nerve using acupuncture needles combined with rehabilitation accelerates nerve regeneration and functional recovery-A case report.

OBJECTIVE: This study illustrates that direct electrical stimulation (ES) improve functional recovery and time of return to work evaluated by prognostic scoring system after ulnar nerve injury. DESIGN: The Rosén and Lundborg (R&L) protocol, Disabilities of the Arm, Shoulder and Hand (DASH) scores, and electromyography were applied for measuring improvements after direct ES intervention. SETTING: A 32-year-old male with deep cutting wound and total rupture of right proximal forearm ulnar nerve was treated using direct ES and daily rehabilitation activities. INTERVENTION: Direct ES, transmitted using 2 acupuncture needles inserted in the cubital tunnel, was applied along the site of the injured ulnar nerve. Other needles were placed according to muscle origins and insertions. All needles were connected to electrical stimulators. We executed these procedures once per week and conducted rehabilitating activities daily. MAIN OUTCOME MEASURES: The R&L protocol, DASH scores, and electromyography were used to measure the intervention outcomes. RESULTS: The total score in the R&L protocol was 0.703 of the initial state; the sensory domain contributed the least amount. Among the improved numerical factors, pain/discomfort domain was the first to reach a stable ameliorative state in the first month. The sensory and motor domains reached stable growth in fourth and third months, respectively. The patient returned to the previous job in third month; his time off work was 75 days. CONCLUSIONS: Directly applying ES to the proximal site of an injured nerve can augment nerve regeneration through three suspected mechanisms. Although direct ES on the injured nerve contributed to an effective recovery of this patient with minimal adverse effects, additional investigation of treatment protocols is warranted and the actual mechanism must be identified.

A histological analysis of human median and ulnar nerves following implantation of Utah slanted electrode arrays.

For decades, epineurial electrodes have been used in clinical therapies involving the stimulation of peripheral nerves. However, next generation peripheral nerve interfaces for applications such as neuroprosthetics would benefit from an increased ability to selectively stimulate and record from nerve tissue. This increased selectivity may require the use of more invasive devices, such as the Utah Slanted Electrode Array (USEA). Previous research with USEAs has described the histological response to the implantation of these devices in cats and rats; however, no such data has been presented in humans. Therefore, we describe here the degree of penetration and foreign body reaction to USEAs after a four-week implantation period in human median and ulnar nerves. We found that current array designs penetrate a relatively small percentage of the available endoneurial tissue in these large nerves. When electrode tips were located within the endoneurial tissue, labels for axons and myelin were found in close proximity to electrodes. Consistent with other reports, we found activated macrophages attached to explanted devices, as well as within the tissue surrounding the implantation site. Despite this inflammatory response, devices were able to successfully record single- or multi-unit action potentials and elicit sensory percepts. However, modifying device design to allow for greater nerve penetration, as well as mitigating the inflammatory response to such devices, would likely increase device performance and should be investigated in future research.

Analysis of the Papal Benediction Sign: The ulnar neuropathy of St. Peter.

The origin of the Papal Benediction Sign has been a source of controversy for many generations of medical students. The question has been whether the Papal Benediction Sign posture is the result of an injury to the median nerve or to the ulnar nerve. The increasingly popular use of online "chat rooms" and the vast quantities of information available on the internet has led to an increasing level of confusion. Looking in major anatomy texts, anatomy and board review books as well as numerous internet sites the answer remains unresolved. Through the analysis of functional anatomy of the hand, cultural and religious practices of the early centuries of the Common Era and church art a clear answer emerges. It will become apparent that this hand posture results from an ulnar neuropathy.

Regimen and results of physiotherapy in patients following surgical treatment of ulnar nerve injury.

BACKGROUND: Ulnar nerve injuries are the most common cause of damage to the nerves of the hand. Diverse mechanisms of injury may be involved, the most frequent being injuries to various areas within the forearm, usually lacerations. In such cases, surgery followed by physiotherapy is a treatment of choice. The aim of the study was to estimate the efficacy of physical therapy following surgical treatment of ulnar nerve injuries. MATERIAL AND METHOD: The study group initially comprised 33 patients. Twelve patients with additional damage to the median nerve were excluded and further analyses concerned a group of 21 patients with ulnar nerve injuries who underwent physiotherapy at the Malopolska Regional Hand Rehabilitation Centre in Cracow. Treatment outcomes were evaluated on the basis of measurements of hand function including the range of motion, function tests as well as sensation and dynamometric tests. RESULTS AND CONCLUSIONS: Range of motion data were used to assess movement impairment according to Swanson's method. The measurements were taken on two occasions before and after the physiotherapy. Analysis of the results revealed significant efficacy of the physiotherapy regimen.

Enhanced sensory relearning after nerve repair by using repeated forearm anaesthesia: aspects on time dynamics of treatment.

BACKGROUND: We describe a new principle for enhancing the effects of sensory re-education following nerve injury and repair. The outcome from nerve repair in adult patients is generally poor. One reason is the functional cortical reorganisation which always occurs because of axonal misdirection at the repair site. In healthy individuals selective anaesthesia of the forearm results in improved hand sensation. Here we hypothesised that this principle would be valid also after nerve injury and repair. METHOD: In a prospective, randomised, double blind study we studied the effects of cutaneous forearm anaesthesia combined with sensory reeducation on the outcome after median or ulnar nerve repair at wrist or distal forearm level. FINDINGS: EMLA-application four times over a two week period starting with beginning reinnervation of the fingers resulted in significantly improved sensory recovery (tactile gnosis) as compared to the placebo group and also at assessment four weeks after the last EMLA-session. However, at assessment 8-11 months after the first EMLA-treatment there was no difference between the groups. CONCLUSIONS: Our findings indicate that repeated cutaneous forearm anaesthesia over a two week period can enhance the effects of sensory re-education at least over the four following weeks. However, the optimal time protocol for EMLA-treatment, aiming at a long-lasting or permanent effect on sensory recovery still has to be defined.

The influence of post-nerve injury survival duration on receptive field size: location, location, location.

In the present study, we examined the relationship between post-injury survival duration and receptive field size at multiple levels of the ascending somatosensory neuroaxis. In experimentally naïve subjects, receptive fields on the glabrous hand are typically restricted to single digits. Yet, following targeted nerve section, receptive fields often span multiple digits. In these experiments, adult squirrel monkeys were subject to paired transections of the median and ulnar nerves and permitted to survive for varying periods (2-28 months) prior to terminal electrophysiological recording. The frequency of cutaneously activated multiple-digit receptive fields was evaluated in regions of brainstem, thalamus and cortex normally devoted to the (now) partially deafferented hand. We report that for area 3b of primary somatosensory cortex, receptive field size became smaller as a function of survival duration. In contrast, survival duration had no appreciable effect on the frequency of multiple-digit receptive fields in either the cuneate nucleus of the brainstem or the ventroposterior lateral nucleus of the thalamus. These observations suggest that the mechanisms responsible for the refinement of receptive fields are, primarily, resident to the cortex.

Muscle preservation using an implantable electrical system after nerve injury and repair.

The value of continuous electrical stimulation of denervated muscles after nerve injury and repair has been clearly shown in a series of laboratory experiments in three animal models. This experimental background, which showed improved muscle preservation and better functional results, evolved into a clinical study that included 15 patients with peripheral nerve injuries in the upper extremities, 3 patients with brachial plexus injuries, and three patients with facial nerve paralysis. Improved functional results were obtained using this implantable system, which were similar to those achieved with the animal experiments. All patients had muscle stimulation for extended periods ranging from 127 to 346 days. Analysis of the results showed satisfactory nerve regeneration on clinical examination and with electromyographic studies. Functional muscle analysis varied somewhat from patient to patient, but every patient had a satisfactory to excellent recovery. The results from this study have clearly shown the benefits of continuous muscle stimulation using an implantable electrical system after nerve injury and repair expansion of the project to a larger patient cohort is indicated.

[A significant increase in superficial sensation, a number of years after a peripheral neurologic lesion, using transcutaneous vibratory stimulation]. / Une augmentation importante de la sensibilité superficielle, de nombreuses années après une lésion neurologique périphérique, par stimulation vibratoire transcutanée.

A patient with sensory changes in the territory of the ulnar nerve due to a partial nerve lesion 19 years previously, was treated by Transcutaneous Vibratory Stimulation. The effectiveness of this treatment was verified by subjective criteria and by the following tests: Moving and Static Two-Point discrimination Test, Light-touch-Deep-pressure (Semmes-Weinstein) Test, Ninhydrin sweat Test and Wrinkle Test. These tests document both a marked improvement in superficial sensitivity and partial regulation of sympathetic nervous system function.

A clinical pilot study to assess functional return following continuous muscle stimulation after nerve injury and repair in the upper extremity using a completely implantable electrical system.

This clinical pilot study evolved from a 10-year experience in the experimental laboratory using continuous muscle stimulation in a series of animal studies following nerve injury and microsurgical repair. A completely implantable system was developed (Medtronic) to provide electrical stimulation to the denervated muscles until nerve regeneration had occurred. Both peripheral nerve injuries in the extremities and facial nerve severances were studied, and a definite improvement in functional capacity was obtained as well as improved morphology compared with nonstimulated controls. In this study, 13 patients with peripheral nerve injuries in the upper extremity are included. All patients had muscle stimulation for extended periods until nerve regeneration was evident; a careful analysis of their functional capacity was then completed. There were five patients with median nerve injuries, four with ulnar nerve or combined median-ulnar nerve injuries, and four with severed radial nerves. All patients showed satisfactory nerve regeneration on clinical examination and electromyographic studies. Motor recovery was usually better than sensory return. Functional muscle analysis varied somewhat from patient to patient, but every patient had a satisfactory to excellent recovery. Patients with low nerve lesions had better results, but muscle recovery even in patients with mid-forearm or higher nerve injuries was most encouraging. Functional recovery in radial nerve injuries was close to normal in all cases. The results from this pilot study have clearly shown the benefits of continuous muscle stimulation using an implantable system following nerve injury and repair.

[Use of combined neuro-myo-electric stimulation in the treatment of compression injuries of the peripheral nerves]. / Primenenie sochetannoi élektroneiromiostimuliatsii dlia lecheniia kompressionnykh povrezhdenii perifericheskikh nervov.

Animal experiments and clinical studies were made to examine the effectiveness of combined neuro-myo-stimulation (conjugated electric stimulation of the injured nerve and muscles and intact reflexogenic areas together with conventional electric stimulation of the nerve) in the treatment of compression ischemic injury to the nerves. The combined neuro-myo-stimulation used in 27 rabbits with experimental compression ischemic injuries to the peripheral nerves made it possible to reduce the time of the recovery of the movements and sensitivity of the paresthetic limb and to reduce vegetative trophic disturbances. This conclusion was supported on the use of the combined neuro-myo-stimulation in the treatment of 16 patients with different injuries to the peripheral nervous system, in whose genesis the main part was played by compression ischemic factors.

Peripheral paresis of upper extremity nerves following supracondylar fracture of the humerus in children.

The authors observed a lesion of the peripheral nerves in 13 of 401 children with supracondylar humerus fractures (3.2%). Most frequently, the radial nerve was injured. All patients with neural lesions healed spontaneously, a surgical revision of the nerve was not necessary. The authors' opinion is that neural lesions accompanying supracondylar fractures can be treated conservatively. Exceptions are clear indications for surgical revision, as persisting ischaemia of the forearm or extensive open fractures. When treating conservatively, it is necessary to make a thorough clinical and EMG investigation to set exactly the diagnosis of the neural lesion immediately after removing the plaster cast (mostly 3 weeks after the injury). This investigation is to be repeated regularly, as the reinervation dynamics of the affected region is to be followed up. At the same time it is advantageous to perform electrostimulation until reinervation potentials appear, vitaminotherapy and intensive active exercise with the involved extremity. If no signs of reinvertion in the affected area appear within 6 months, a surgical revision of the nerve is to be considered.

[Clinico-physiological characteristics of the effectiveness of conservative therapy in traumatic neuropathies]. / Kliniko-fiziologicheskaia kharakteristika éffektivnosti konservativnoi terapii travmaticheskikh nevropatii.

The effect of electroneuromyostimulation (ENMS) combined with Nootropil administration for trauma neuropathies was assessed using clinical and physiological tests in 58 patients. The combined intervention considerably accelerated the restoration of motor and sensory functions after the reconstructive neurosurgery on the extremities. Sensory functions substantially improved in 78% of the patients receiving ENMS and Nootropil and in 23% of those receiving the conventional treatment. The ENMS plus Nootropil treatment has been found to have advantages as compared with the conventional one.

Long-term pain control by direct peripheral-nerve stimulation.

In 1970, we began implanting electrodes for prolonged stimulation of injured peripheral nerves to reduce chronic pain. Thirty-eight peripheral nerves in thirty-five patients have been stimulated with electrodes for a period ranging from four to nine years. Nineteen electrode systems were implanted in the upper extremity (eleven on the median nerve, six on the ulnar nerve, one on the median and ulnar nerves, and one on the median and radial nerves), with successful relief of pain in 52..6 per cent of the patients. Sixteen stimulators have been implanted on the sciatic nerve with a success rate for pain relief of 31 per cent. Failures in the lower extremity were found primarily in lesions of the posterior tibial nerve at the ankle. We speculate that the stress of weight-bearing and the anatomical position of the posterior tibial nerve may partially account for this rate of failure. Use of the electrode-implant systems required careful preoperative assessment by an experienced team, meticulous technique, and a mechanical system that tolerates stress. The location and characteristics of the lesion affect the response to electrical stimulation.