Rehabilitation of peripheral nerve injuries

Beyond the Knife-Reviewing the Interplay of Psychosocial Factors and Peripheral Nerve Lesions

Peripheral nerve injuries are a common clinical problem. They not only affect the physical capabilities of the injured person due to loss of motor or sensory function but also have a significant impact on psychosocial aspects of life. The aim of this work is to review the interplay of psychosocial factors and peripheral nerve lesions. By reviewing the published literature, we identified several factors to be heavily influenced by peripheral nerve lesions. In addition to psychological factors like pain, depression, catastrophizing and stress, social factors like employment status and worker's compensation status could be identified to be influenced by peripheral nerve lesions as well as serving as predictors of functional outcome themselves, respectively. This work sheds a light not only on the impact of peripheral nerve lesions on psychosocial aspects of life, but also on the prognostic values of these factors of functional outcome. Interdisciplinary, individualized treatment of patients is required to identify patient at risk for adverse outcomes and provide them with emotional support when adapting to their new life situation.

Efficacy of electrical stimulation of denervated muscle: A multicenter, double-blind, randomized clinical trial

BACKGROUND

This was a multicenter, double-blind, randomized clinical trial to investigate the efficacy of electrical stimulation of denervated muscle (ESDM) on recovery of patients with peripheral nerve injuries.

METHODS

We enrolled 38 patients with traumatic peripheral nerve injuries with axonal damage and clinical impairment of two muscles, who were randomly treated with real or sham electrical stimulation (ES). Clinical and neurophysiological examinations were performed before treatment, at the end of treatment, and 3 mo posttreatment, by the same physician who was blinded to the ES allocation.

RESULTS

All patients improved but there was no significant beneficial effect of ESDM compared with sham treatment.

CONCLUSIONS

This study failed to demonstrate the efficacy of ESDM for peripheral nerve injuries. However, given the large number of variables related to ES and the heterogeneity in disease etiologies and clinical manifestations, future studies on homogeneous populations using different stimulation protocols may be useful.

TGF-β1 activates RSC96 Schwann cells migration and invasion through MMP-2 and MMP-9 activities

Following peripheral nerve injury, remnant Schwann cells adopt a migratory phenotype and remodel the extracellular matrix allowing axonal regrowth. Although much evidence has demonstrated that TGF-β1 promotes glioma cell motility and induces the expression of extracellular matrix proteins, the effects of TGF-β1 on Schwann cell migration has not yet been studied. We therefore investigated the cellular effects and the signal transduction pathways evoked by TGF-β1 in rattus norvegicus neuronal Schwann RSC96 cell. TGF-β1 significantly increased migration and invasion of Schwann cells assessed by the wound-healing assay and by cell invasion assay. TGF-β1-enhanced migration/invasion was blocked by inhibition of MMP-2 and MMP-9. Consistently, by real-time and western blot analyses, we demonstrated that TGF-β1 increased MMP-2 and MMP-9 mRNA and protein levels. TGF-β1 also increased MMPs activities in cell growth medium, as shown by gelatin zymography. The selective TGF-β Type I receptor inhibitor SB431542 completely abrogated any effects by TGF-β1. Indeed, TGF-β1 Type I receptor activation provoked the cytosol-to-nucleus translocation of SMAD2 and SMAD3. SMAD2 knockdown by siRNA blocked MMP-2 induction and cell migration/invasion due to TGF-β1. TGF-β1 also provoked phosphorylation of MAPKs extracellular regulated kinase 1/2 and JNK1/2. Both MAPKs were upstream to p65/NF-kB inasmuch as both MAPKs' inhibitors PD98059 and SP600125 or their down-regulation by siRNA significantly blocked the TGF-β1-induced nuclear translocation of p65/NF-kB. In addition, p65/NF-κB siRNA knockdown inhibited the effects of TGF-β1 on both MMP-9 and cell migration/invasion. We conclude that TGF-β1 controls RSC96 Schwann cell migration and invasion through MMP-2 and MMP-9 activities. MMP-2 is controlled by SMAD2 whilst MMP-9 is controlled via an ERK1/2-JNK1/2-NF-κB dependent pathway.

Effect of swimming training on nerve morphological recovery after compressive injury

OBJECTIVE

This study aims to investigate morphological alterations caused by partial sciatic nerve ligation (PNL) and the efficacy of a moderate-intensity swimming training as therapeutic strategy for nerve regeneration.

METHODS

A number of 30 male adult mice were equally divided in control, 14 days after PNL (PNL 14 days), 42 days after PNL (PNL 42 days), 70 days after PNL (PNL 70 days) and 5-week exercise training after 7 days post-lesion (PNL trained 35 days) groups. PNL trained 35 days group began with a 10-min session for 3 days and this time was gradually increased by 10 min every three sessions until the animals had swum for 50 min per session. Morphoquantitative analysis was carried out to assess nerve regeneration in each group.

RESULTS

PNL 14 days group exhibited less degenerating signs than PNL 42 days group, where most post-lesion alterations were visualized. Nerve area and minimum diameter were significantly lower (p < 0.05) than control group. PNL 70 days group showed a greater degree of regenerating fibers and similar morphometric parameters to control group. PNL trained 35 days demonstrated signs of regeneration, reaching control group values in the morphometric analysis.

DISCUSSION

PNL promotes great histopathological changes, which became more visible at 42 post-injury days. A natural nerve-regeneration tendency was observed throughout time, as observed in PNL 70 days group; nevertheless, moderate swimming training was found to be a therapeutic resource for nerve regeneration, accelerating such process from a morphoquantitative perspective.

ABBREVIATIONS

ANOVA: One-way analysis of variance; BDNF: Brain-derived neurotrophic factor; FGF-2: Fibroblast growth factor 2; GDNF: Glial cell line derived neurotrophic factor; IGF: Insulin-link growth factor; IL-1β: Interleukin-1β; NGF: Neural growth factor; PBS: Phosphate-buffered saline; PNL: Partial sciatic nerve ligation.

A comparative study of rehabilitation therapy in traumatic upper limb peripheral nerve injuries

INTRODUCTION

Lower motor neurons are the only neurons of the central nervous system (CNS) with the ability to regenerate without any intervention after an axotomy.

AIM

This present study was conducted to analyze clinical and electrophysiological parameters in four groups of upper limb peripheral neuropathies, before and after treatment, comparing the results obtained after three cures of complex rehabilitation therapy.

MATERIALS AND METHODS

We selected a number of 107 patients (66 women and 41 men) aged between 29 and 77 years (mean age = 49.6). Clinical (muscular strength, sensitivity) and electrophysiological parameters (accommodation coefficient α, nerve conduction velocity) were analyzed. All patients received 3 comprehensive treatment cures, each cure of 14 days and a rest period of 3 months between the cures.

RESULTS

From the total of 107 patients included in the study, 52 were diagnosed with brachial plexus palsy, 27 with radial nerve palsy, 18 with median nerve palsy and 10 with ulnar nerve palsy. We did not observe a statistically significant difference between the mean age of males (47.2) and females (51.2) (p = 0.07), but peripheral neuropathies were more common in young males. At the end of the rehabilitation treatment all patients achieved better outcomes in muscle strength, sensitivity, adjustment coefficient α and nerve conduction velocity (p < 0.001).CONCLUSIONThe intervention of a physical therapy program in patients with peripheral neuropathies provided significantly better outcomes in clinical and electrophysiological parameters. Our rehabilitation protocol can be considered an alternative in order to stimulate and accelerate the nerve regeneration process.

Effects of swimming exercise on nerve regeneration in a rat sciatic nerve transection model

Background: Swimming is commonly considered to be an efficient rehabilitation exercise to treat peripheral nerve injury. However, the most effective resistance level and exercise duration is still unclear. We investigated the effects and mechanisms of swimming at various exertion levels in a rat sciatic nerve transection model.

Methods: Sciatic nerve transection rats were randomized into the following four groups based on swimming duration (from the 7th day to the 28th day post-surgery): sedentary control group (SC), S10 group (10 min/3 times/week), S20 group (20 min/3 times/week), and S30 group (30 min/3 times/week) (n = 10 each). Axon regeneration, electrophysiological properties, muscular weights, macrophage infiltration, and nerve repair associated maker, calcitonin gene-related peptide (CGRP), were measured.

Results: Dramatic higher successful percentages of nerve regeneration across the 10-mm gaps in swimming groups compared to the SC group. Total area of nerve regeneration significantly improved in the S10 group; however, electrophysiological properties, muscular weights, and macrophage infiltration in the regenerated nerves of rats did not differ significantly between the various exercise groups. CGRP expression was significantly increased in the spinal cord of rats in the S20 group.

Conclusions: Our data indicated that CGRP-related axonal regeneration improved significantly with moderate swimming. These results should inspire new studies in physiotherapeutic practice for related human treatment.

Sarcoma excision and pattern of complicating sensory neuropathy

A potential complication of sarcoma excision surgery is a sensory neurological dysfunction around the surgical scar. This study utilised both objective and subjective sensation assessment modalities, to evaluate 22 patients after sarcoma surgery, for a sensory deficit. 93% had an objective sensory deficit. Light touch is less likely to be damaged than pinprick sensation, and two-point discrimination is significantly reduced around the scar. Results also show that an increased scar size leads to an increased light touch and pinprick deficit and that two-point discriminatory ability around the scar improves as time after surgery elapses. 91% had a subjective deficit, most likely tingling or pain, and numbness was most probable with lower limb sarcomas. Results also demonstrated that there were no significant relationships between any specific subjective and objective deficits. In conclusion, sensory disturbance after sarcoma surgery is common and debilitating. Efforts to minimize scar length are paramount in the prevention of sensory deficit. Sensation may also recover to an extent; thus, sensory reeducation techniques must become an integral aspect of management plans. Finally to obtain a comprehensive assessment of sensory function, both objective and subjective assessment techniques must be utilised.

Neuregulin facilitates nerve regeneration by speeding Schwann cell migration via ErbB2/3-dependent FAK pathway

Background

Adequate migration of Schwann cells (Sc) is crucial for axon-guidance in the regenerative process after peripheral nerve injury (PNI). Considering neuregulin-erbB-FAK signaling is an essential pathway participating in the regulation of Sc migration during development, the present study is aimed to examine whether neuregulin would exert its beneficial effects on adult following PNI and further determine the potential changes of downstream pathway engaged in neuro-regeneration by both in vitro and in vivo approaches.

Methodology and Principal Findings

Cultured RSC96 cells treated with neuregulin were processed for erbB2/3 immunofluorescence and FAK immunoblotings. The potential effects of neuregulin on Sc were assessed by cell adherence, spreading, and migration assays. In order to evaluate the functional significance of neuregulin on neuro-regeneration, the in vivo model of PNI was performed by chronic end-to-side neurorrhaphy (ESN). In vitro studies indicated that after neuregulin incubation, erbB2/3 were not only expressed in cell membranes, but also distributed throughout the cytoplasm and nucleus of RSC96 cells. Activation of erbB2/3 was positively correlated with FAK phosphorylation. Neuregulin also increases Sc adherence, spreading, and migration by 127.2±5.0%, 336.8±3.0%, and 80.0±5.7%, respectively. As for in vivo study, neuregulin significantly accelerates the speed of Sc migration and increases Sc expression in the distal stump of injured nerves. Retrograde labeling and compound muscle action potential recordings (CMAP) also showed that neuregulin successfully facilitates nerve regeneration by eliciting noticeably larger CMAP and promoting quick re-innervation of target muscles.

Conclusions

As neuregulin successfully improves axo-glial interaction by speeding Sc migration via the erbB2/3-FAK pathway, therapeutic use of neuregulin may thus serve as a promising strategy to facilitate the progress of nerve regeneration after PNI.

Melatonin preserves superoxide dismutase activity in hypoglossal motoneurons of adult rats following peripheral nerve injury

Peripheral nerve injury (PNI) produces functional changes in lesioned neurons in which oxidative stress is considered to be the main cause of neuronal damage. As superoxide dismutase (SOD) is an important antioxidative enzyme involved in redox regulation of oxidative stress, the present study determined whether melatonin would exert its beneficial effects by preserving the SOD reactivity following PNI. Adult rats subjected to hypoglossal nerve transection were intraperitoneally injected with melatonin at ones for 3, 7, 14, 30 and 60 days successively. The potential neuroprotective effects of melatonin were quantitatively demonstrated by neuronal nitric oxide synthase (nNOS), mitochondrial manganese SOD (Mn-SOD), and cytosolic copper-zinc SOD (Cu/Zn-SOD) immunohistochemistry. The functional recovery of the lesioned neurons was evaluated by choline acetyltransferase (ChAT) immunohistochemistry along with the electromyographic (EMG) recordings of denervation-induced fibrillation activity. The results indicate that following PNI, the nNOS immunoreactivity was significantly increased in lesioned neurons peaking at 14 days. The up-regulation of nNOS temporally coincided with the reduction of ChAT and SOD in which the Cu/Zn-SOD showed a greater diminution than Mn-SOD. However, following melatonin administration, the nNOS augmentation was successfully suppressed and the activities of Mn-SOD, Cu/Zn-SOD, and ChAT were effectively preserved at all postaxotomy periods. EMG data also showed a decreased fibrillation in melatonin-treated groups, suggesting a potential effect of melatonin in promoting functional recovery. In association with its significant capacity in preserving SOD reactivity, melatonin is suggested to serve as a powerful therapeutic agent for treating PNI-relevant oxidative damage.

Neural plasticity after peripheral nerve injury and regeneration

Injuries to the peripheral nerves result in partial or total loss of motor, sensory and autonomic functions conveyed by the lesioned nerves to the denervated segments of the body, due to the interruption of axons continuity, degeneration of nerve fibers distal to the lesion and eventual death of axotomized neurons. Injuries to the peripheral nervous system may thus result in considerable disability. After axotomy, neuronal phenotype switches from a transmitter to a regenerative state, inducing the down- and up-regulation of numerous cellular components as well as the synthesis de novo of some molecules normally not expressed in adult neurons. These changes in gene expression activate and regulate the pathways responsible for neuronal survival and axonal regeneration. Functional deficits caused by nerve injuries can be compensated by three neural mechanisms: the reinnervation of denervated targets by regeneration of injured axons, the reinnervation by collateral branching of undamaged axons, and the remodeling of nervous system circuitry related to the lost functions. Plasticity of central connections may compensate functionally for the lack of specificity in target reinnervation; plasticity in human has, however, limited effects on disturbed sensory localization or fine motor control after injuries, and may even result in maladaptive changes, such as neuropathic pain, hyperreflexia and dystonia. Recent research has uncovered that peripheral nerve injuries induce a concurrent cascade of events, at the systemic, cellular and molecular levels, initiated by the nerve injury and progressing throughout plastic changes at the spinal cord, brainstem relay nuclei, thalamus and brain cortex. Mechanisms for these changes are ubiquitous in central substrates and include neurochemical changes, functional alterations of excitatory and inhibitory connections, atrophy and degeneration of normal substrates, sprouting of new connections, and reorganization of somatosensory and motor maps. An important direction for ongoing research is the development of therapeutic strategies that enhance axonal regeneration, promote selective target reinnervation, but are also able to modulate central nervous system reorganization, amplifying those positive adaptive changes that help to improve functional recovery but also diminishing undesirable consequences.

Electrical stimulation of denervated muscles

PURPOSE

In this report, the 3-year rehabilitation of a 43-year-old male patient, who have pelvic 'open book' fracture, urinary bladder and urethral injury, lumbosacral plexus avulsion trauma and right lower extremity monoparesis is explained.

METHOD

Rehabilitation of these injuries is absolutely essential to ensure optimal functional recovery. But the value of electrical stimulation for denervated muscle is not proven and its application to gain what may only be a small benefit is often not justified.

CONCLUSIONS

With this case I emphasize that electrical stimulation and appropriate exercise programme in denervated protected muscle fibers activity for 3 years and rehabilitation should be continued.