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Stimulus Electrodiagnosis and Motor and Functional Evaluations During Ulnar Nerve Recovery

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Stimulus Electrodiagnosis and Motor and Functional Evaluations During Ulnar Nerve Recovery original article Stimulus electrodiagnosis and motor and functional evaluations during ulnar nerve recovery Luciane F. R. M. Fernandes1, Nuno M. L. Oliveira1, Danyelle C. S. Pelet2, Agnes F. S. Cunha2, Marco A. S. Grecco3, Luciane A. P. S. Souza1 ABSTRACT | Background: Distal ulnar nerve injury leads to impairment of hand function due to motor and sensorial changes. Stimulus electrodiagnosis (SE) is a method of assessing and monitoring the development of this type of injury. Objective: To identify the most sensitive electrodiagnostic parameters to evaluate ulnar nerve recovery and to correlate these parameters (Rheobase, Chronaxie, and Accommodation) with motor function evaluations. Method: A prospective cohort study of ten patients submitted to ulnar neurorrhaphy and evaluated using electrodiagnosis and motor assessment at two moments of neural recovery. A functional evaluation using the DASH questionnaire (Disability of the Arm, Shoulder, and Hand) was conducted at the end to establish the functional status of the upper limb. Results: There was significant reduction only in the Chronaxie values in relation to time of injury and side (with and without lesion), as well as significant correlation of Chronaxie with the motor domain score.Conclusion : Chronaxie was the most sensitive SE parameter for detecting differences in neuromuscular responses during the ulnar nerve recovery process and it was the only parameter correlated with the motor assessment. Keywords: chronaxie; ulnar nerve; evaluation studies; disability evaluation; rehabilitation; movement. BULLET POINTS • Stimulus electrodiagnosis is a reliable, noninvasive method of identifying neural regeneration. • Chronaxie was the most sensitive parameter for assessing ulnar regeneration. • Chronaxie and motor evaluation should be used to monitor neural regeneration. HOW TO CITE THIS ARTICLE Fernandes LFRM, Oliveira NML, Pelet DCS, Cunha AFS, Grecco MAS, Souza LAPS. Stimulus electrodiagnosis and motor and functional evaluations during ulnar nerve recovery. Braz J Phys Ther. 2016 Mar-Apr; 20(2):126-132 . http://dx.doi.org/10.1590/bjpt-rbf.2014.0138 Introduction Injury to the ulnar nerve is one of the most common Regarding functional evaluation, the DASH (Disability upper limb peripheral nerve lesions. Eser et al.1 of the Arm, Shoulder, and Hand) questionnaire3, conducted a retrospective study and found that which consists of three modules, employs a series of most cases involved lesions of the ulnar nerve, with questions related to different tasks involving the upper 337 cases (27%), followed by lesions of the median limbs. This instrument was developed to measure nerve, with 273 cases (22%). A complete and detailed dysfunction and physical symptoms in the upper evaluation of the hand is essential in order to identify limbs and to evaluate progress over time3. a suitable treatment and achieve the best response to Among the various means of evaluating peripheral therapy. Rosén and Lundborg2 developed a model nerve lesions, a traditional physical therapeutic for the specific evaluation of median and ulnar nerve resource, which has nonetheless been infrequently lesions, considering three domains: motor, sensory, utilized, is stimulus electrodiagnosis (SE). It is a and pain/discomfort. In the motor domain, evaluation reliable, noninvasive method of monitoring neural of the median and ulnar nerves involves testing the conditions and recovery progress4,5. In addition to its strength of key hand muscles, along with dynamometry use for evaluation purposes, SE is the only resource measurements of handgrip strength. available to establish the ideal conditions of therapeutic 1 Departamento de Fisioterapia Aplicada, Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil 2 Curso de Fisioterapia, Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil 3 Departamento de Cirurgia, Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil Received: Dec. 18, 2014 Revised: June 30, 2015 Accepted: Oct. 06, 2015 126 Braz J Phys Ther. 2016 Mar-Apr; 20(2):126-132 http://dx.doi.org/10.1590/bjpt-rbf.2014.0138 Stimulus electrodiagnosis in nerve lesion electrostimulation, ensuring use of the most suitable to attend the evaluations, and absence of muscular electrical pulse for treatment of a specific lesion4,5. response during the electrodiagnosis examination. SE is one of the most objective means of evaluating A sample size of nine patients was determined, based and monitoring the evolution of a peripheral nerve on the standard deviation values of 3.03 obtained for lesion4,6,7, and of guiding the use of therapeutic Chronaxie in a pilot project involving five patients electrostimulation5. In the present study, we attempted with ulnar nerve lesions. Sample size estimation was to test the efficiency and the importance of SE as a calculated using Power and Sample v.3.0.4 software ‘tool-of-the-trade’ for physical therapists, particularly with power of 80% and α=0.05. The Chronaxie in ulnar nerve recovery. variable was selected due to its recognized importance 4,8,9 There are no reports in literature concerning the in electrodiagnostic examinations . use of SE in upper limb peripheral nerve lesions. The study was conducted with ten patients, No protocols have been defined for electrostimulation, including six men and four women with a mean age and no studies have investigated the relationship of 42 (SD=15) years. In the sample, only one subject was left-handed, and the right-hand side was more between SE parameters and the results of physical severely affected by lesions acquired in the workplace. therapeutic evaluation. If a good relationship is found, All of the patients underwent neurorrhaphy, carried it could emphasize the importance of SE in the process out by the same medical team, and were referred of nerve lesion recovery and rehabilitation. Thus, the to the same physical therapy service at the UFTM, hypothesis of this study was that the SE parameters which followed the same protocol developed for the correlate with motor scores during peripheral ulnar study. Nine patients underwent surgery in the first lesion recovery. The objective of this study, therefore, three weeks following injury. was to identify the most sensitive parameters to use for Two evaluations of the injured limb were performed: the evaluation of ulnar nerve recovery and to correlate initial (EV1) and final (EV2). EV1 was conducted the SE parameter values with motor performance. during the initial phase (between 4 and 6 months The neuromuscular responses, which were obtained post-surgery) and EV2 was performed at a later using electrodiagnosis during the recovery process stage (between 10 and 15 months post-surgery). after neurorrhaphy of the ulnar nerve, were evaluated, Evaluations (denoted EVWL) were also made on the and the electrodiagnosis parameters were correlated contralateral limb (i.e. without lesion). All evaluations with the results of motor assessments. Our objective were conducted by the same examiner and under the was to determine whether the motor gains are linked same conditions. to neural recovery, showing a possible new use for SE. Equipment and functional evaluation Method The equipment used for the SE tests included: a) a universal pulse generator (Model Nemesys 941, Quark, Subjects Brazil); b) aluminum electrodes (10×5 cm); c) natural An observational, prospective cohort study was plant sponges (10×5 cm); d) an electrodiagnosis carried out to investigate the recovery of the ulnar pen; and e) evaluation sheets (available from the nerve after neurorrhaphy. All subjects received instrument manual). For the motor assessment, a information about the objectives and procedures of hydraulic dynamometer (Jamar) was used, and the the study and signed an informed consent form, in functional evaluation was conducted using the DASH accordance with regulation 466/12 of the Brazilian questionnaire that had been translated and validated National Health Council. The study was approved for use in Portuguese10,11. by the ethics committee of Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil Electrodiagnostic testing (protocol number 1663). The inclusion criteria selected The parameters considered in the SE were patients with ulnar nerve lesions in the region of the Rheobase, Chronaxie, and Accommodation. Rheobase wrist and distal forearm and who had been submitted corresponds to the minimum stimulation intensity to neurorrhaphy and then underwent physical able to produce the smallest muscular contraction that therapy during the first three months after surgery. can be perceived visually. This was achieved using The exclusion criteria were refusal to participate in the a rectangular pulse with a period (T) of 1.0 s and an study, postoperative complications (infection), failure interval between pulses (R) of 2.0 s8,12,13. Chronaxie Braz J Phys Ther. 2016 Mar-Apr; 20(2):126-132 127 Fernandes LFRM, Oliveira NML, Pelet DCS, Cunha AFS, Grecco MAS, Souza LAPS corresponds to the shortest time necessary to produce five, according to the Highet scale15, and the values a muscular contraction, also using a rectangular pulse obtained for the three muscles were added and divided with an interval of 2.0 s and an amplitude equal to by 15 (the value for a normal individual). two times the Rheobase obtained previously8,12,14. The position adopted for measurements of grip Accommodation is defined similarly to Rheobase, but strength was that recommended by the American Society the measurement
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