REHABILITATION OF ACUTE PERIPHERAL NEUROPATHIES – COMMENTS ON A CLINICAL CASE

The study covers the staged rehabilitation treatment of a 13-year-old patient diagnosed with acute demyelinating polyradiculoneuritis.
The treatment aimed at:

• preventing muscle-tendon contractions
• managing pain
• monitoring respiratory problems
• rehabilitating motor skills

The following steps were taken:

• correct positioning with frequent posture change
• orthosing
• stretching
• passive, then active analytical kinetotherapy, global kinetotherapy, ending with orthostatism and walking.
• respiratory assistance
• electrostimulations
• occupational therapy.

During the remission phase after resuming walking, he benefited from kinetotherapy and hydro-kinetotherapy out of hospital as recommended.
The condition was considered remitted at the check up carried out 12 months from the onset.

The study covers the staged rehabilitation treatment of a 13-year-old patient diagnosed with acute demyelinating polyradiculoneuritis.
The treatment aimed at:

• preventing muscle-tendon contractions :
• managing pain ;
• monitoring respiratory problems ;
• rehabilitating motor skills .

The following steps were taken:

• correct positioning with frequent posture change ;
• orthosing ;
• stretching ;
• passive, then active analytical kinetotherapy, global kinetotherapy, ending with orthostatism and walking ;
• respiratory assistance ;
• electrostimulations ;
• occupational therapy .
• During the remission phase after resuming walking, he benefited from kinetotherapy and hydro-kinetotherapy out of hospital as recommended.

The condition was considered remitted at the check up carried out 12 months from the onset.
In November 2012, ZR, a 13-year-old male child was transferred to the Neuropediatric Section of Al. Obregia Hospital, on a diagnostic of acute demyelinating polyradiculoneuritis, displaying:

• low tone of eylid orbicularis muscle ;
• slight neck stiffness ;
• rahialgias, myalgias ;
• low tone of lower limb (LL) muscles, level 3-4 ;
• incipient retraction of sural triceps muscles ;
• distal paresthaesiae at the level of the LL ;
• algic and thermic hypoesthaesia at the level of the LL ;
• anteversion and abversion of the upper limbs (UL) under 90 degrees and with difficulty ;
• proximally and distally low muscle strength in upper limbs (UL), level 3-4 ;
• distal hypoesthesia in UL ;
• the patient only raises from dorsal decubitus (DD) in sitting and then in orthostatic position with help ;
• titubant ataxic, wide based gait .
• Achillean deep osteo-tendinous reflexes (OTR) present, absent for the remainder, Plantar skin reflexes (PSR) in flexion, absent abdominal skin reflexes (ASR).

No sphincter disfunctions:
Laboratory examination: ASLO – 221.91, ESR 12mm/h, total Ca 10.5 mg%, CK 33 u/l, LDH
178 u/l, Potassium 4.2 mmol/l, Sodium 138 mmol/l, reactive prot C 1.9mg/l, TGO 11u/l, TGP 11 u/l, Spinal tap: LCR clear, colourless, normotensive, microalbumines 42.3 mg/dl, proteins – 436.5/dl, glucose – 73mg/dl, elementary nucleates – 4/ml, polymorphonuclears 95%, limphocites 5%.

EKG within normal limits:
VCM: low values bilateral peroneal nerve, posterior tibial and left medial. A specific medication is started (octagam, gabapentin, marcofen, algocalmin(metamizole)).
The patient is in the extension period.
Rehabilitation measures:
caregivers are instructed as to the patient ’s positioning and mobilization ;
ankle –leg orthoses are made ;
mild passive mobilisations are applied in all limb joints, mild stretching of the sural triceps, respiration exercises, thoracic tapping .
After several days of motor skills regression, the child no longer maintains orthostatic position, neck stiffness, rahialgias, and mialgias increase, amiotrophies are present in ULs and LLs, difficulties in solid food swallowing appear.
The patient is transferred to the University Hospital for plasmapheresis.
After seven days he returns to the Neuropaediatric Section with an improved health status, less intense myalgia, he performs UL abduction and anteduction to 90 degrees against gravity, extensions in the metacarpo-falangian and interfalangian articulations, he performs flexions and extensions of the LL from DD, the tricipital retraction has diminished, allowing passive leg dorsiflexion at 90 degrees (active flexion absent).

The patient turns actively form DD into lateral decubitus (LD). He flexes his head – neck actively about 25 degrees.
OTR absent, except for the bicipital one.

It is recommended:

• to perform stretching for the sural triceps ;
• to maintain leg /foot orthosis ;
• analytical exercises for the affected muscles ;
• mobilisations from DD into LD and VD ;
• to rise in bed side sitting position, then in orthostatic position ;
• TENS (Transcutaneous Electrical Nerve Stimulation );
• hydrokinetotherapy at Băile Olănești resort .

When readmitted, after 3 months, for check-up (March 2013), obvious improvement is noticed:

• independent gait possible, with slightly wider base, difficult tiptoe and heel gait ;
• able to raise from crouched to orthostatic position ;
• no retractions of muscles and tendons, but still difficult active dorsiflexion of legs ;
• general muscle tone of value 3 -4, amyotrophy ;
• no sensitivity disorders ;
• persisting pains in lower legs ;
• distal amyotrophy in UL, low muscle tone, no sensitivity disorders ;
• absent ORT .

It is recommended:

• stretching for the sural triceps muscle; to maintain lower leg – foot orthosis ;
• analytical exercices for the affected muscles ;
• mobilisations from DD into LD and VD ;
• repeated rises to bed side sitting position, then to orthostatic position ;

TENS;

• hydrokinetotherapy at Băile Olănești spa .
• When readmitted for check-up after three months (March 2013), obvious improvement is noticed:
• independant gait possible, with slightly wider base, difficult tiptoe and heel gait ;
• patient able to raise from crouched to orthostatic position; no retractions of muscles and tendons, but still difficult active dorsiflexion of legs ;
• general muscle tone of value 3 -4, amyotrophy ;
• no sensitivity disorders ;
• persisting pains in lower legs ;
• distal amyotrophy in UL, low muscle tone, no sensitivity disorders ;
• absent ORT .
• The patient is in a plateau phase, with stable motor deficit, and variable neurological affectation.
• Active kinetotherapy may be initiated. Caution not to induce muscular fatigue!

On discharge, besides medication, it is recommended:

• kinetotherapy with elements of proprioceptive neuromuscular facilitation ;
• exercises for postural balance ;
• pelvic stabilising muscle toning ;
• respiratory gymnastics ;
• exercises for reorganising usual gestures (occupational therapy );
• hydrokinetotherapy .
• In August 2013, a new check-up:
• a slight eyelid low tone maintains ;
• improved muscle tone, at 4-5 value ;
• normal gait, possible tip-toe and heel gait; he hops ;
• muscle –tendon retractions absent ;
• distally decreased muscle tone maintained in UL, amyotrophy ;
• ORT are present except for the achillian – absent.

The patient is in full recovery period.
It is recommended to continue with global active kinetotherapy, hydrokynetotherapy.

The patient comes for a further check-up in December 2013. He displays:

• residual orbicular eyelid hypotony ;
• normal independent gait, gait on tiptoes and heels ;
• normal muscular tone ;
• normal muscular strength, except for the deltoid, supreaspinotus and the palmar interossei (value 4 );
• absent muscle tendon retractions and muscle atrophy ;
• sensitivity disorders absent ;
• present ORT, except for the achillian .

It is recommended to continue kinetotherapy and swimming.

To note:

• In case of acute peripheral neuropathies, there is a first extention phase (between 2 weeks and several months) when the objectives are:
• to prevent muscle tendon retractions ;
• pain management ;
• to attend respiratory problems .

The following steps are taken:

• frequent changes of postures to prevent retractions and pain ;
• stretching to prevent retractions and lowering of sarcomere numbers ;
• orthosing (5, 12, 17).
• A cushion is placed at the level of the popliteal space for short periods of time, for the rest of the time the knees remain in extension.
• In UL: the shoulders maintain in abduction and intermediary rotation, the elbows in slight flexion, the forearms in slight supination, the fists in extension 20 -30 degrees. (13, 16, 17)
• pain management: medication, vibrations, perhaps very mild ;
• very slow passive mobilisations to maintain joint flexibility, cartillage nutrition and proprioceptive information flow towards the CNV (10 );
• respiratory assistance: apply vibrating pressure to accelerate the respiratory flow. In serious cases the patient shall be ventilated to prevent atelectasia. (18 ).
• After the extension phase the plateau phase follows, when lesions are stabilised. This can last for 2 – 6 – 8 weeks. A plateau phase extended excessively suggests an unfavourable prognosis:
• kinetotherapy starts analytically, according to the affected muscle groups. Exert caution for deep sensitivity alterations as movement direction and joint position alterations generate alterations in gait and prehension. (7, 12 )

The recovery phase follows, which is the longest one, lasting for 6 months to 2 years on average. After 2 years since the onset, sequelae can be thought of and surgery is considered.
The therapy provides a combination of analytical and global exercices, including:

• proprioceptive facilitation elements ;
• tonifying the body, pelvis and LL stabilising muscles .

To note that exercises aimed at one muscle are preferred to a general strength training. For example focusing on leg dorsiflexion will increase the chances of ambulation (3, 16, 18).
to reorganise usual gestures, girdle dissociation, rollings, walks on all four, knight’s kneeling and gradual verticalisation are initiatied.

• balance exercises in orthostatism, walking within parallel bars, working in front of a mirror so as to have the benefit of visual information (7, 10, 15 );
• pressure applied during passive and active mobilisations for proprioceptive reinformation ;
• continuing stretching, pain fighting, TENS ;
• hand orthosis in case of intrinsic muscle paralysis ;
• occupational therapy for increasing hand moving ability ;
• muscle electrostimulation so as to maintain muscle mass and facilitate voluntary contraction (pay attention to the areas experiencing sensitivity disorders!) (8 ).

The same muscle fibres shall not be targeted for extended periods of time, lest fatigue occur. Different muscles shall be stimulated in turn, in their motor points, progressively increasing the current intensity (8, 9, 19).
resuming walking is generally possible after one month in 40% of the cases, after three months in 20% of the cases while the outstanding 40% maintain various functional or orthopedic deficits: club foot, genu flexum, hip flexum, metacarpophalangeal and interphalangeal joint stiffness .
Some patients can benefit from partial body-weight support systems with a view to resuming independent walking. After a four week experiment with 40% of the body weight supported, an increase in walking speed and an extended covered lapse were noticed in the 6 minute walk test. (19)
Sensitivity disorders regress progressively, except for those of deep sensitivity, which can remain permanent. (7)
A complication of neuropathies is represented by types of compression like the carpal tunnel syndrome.
This will imply immediate orthosing of the fist, concomitantly with injecting corticosteroids in the carpal tunnel, slow stretching, cryotherapy (1, 6, 19).
In case improvement is not obtained in seven weeks, surgery is effected, immediately followed by movements meant to prevent join blocking and to ensure adequate gliding of tendons and of the median nerve in the carpal tunnel. (6)
Psychological support is sometimes beneficial in cases of acute peripheral neuropathies especially those involving prolongued immobilisation and pains that can generate depressive disorders.
Rehabilitation in such conditions requires a multidisciplinary approach, the neurologist being joined by specialists in many other fields: laboratory, recovery, occupational therapy, the kinetotherapist, psychologist, orthotist, surgeon, anesthetist, the whole team supporting the pacient for a fast and complete healing.

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