Sensory Reeducation

This is when the nerve sheath is repaired and new nerve axons grow into the skin and muscles, after a nerve repair surgery in the hand. (Rosen, 2006) The growth of the nerve fibres is slow and may grow about one 2.5cm every month in ideal conditions. Depending on many factors such as the length that the nerve needs to grow. As well as the muscles to work well together again. This can take many months for the nerve to finish growing after an injury.

(Hand, 2015)

A peripheral nerve injury can become problematic as our hands serve many purposes, they help us wash, eat, dress, brush our teeth, write, work and do many other leisure activities. They improve our quality of life. To accomplish these tasks and activities, our hands require sensation and movement. (Council., 2009) When looking at the role of occupational therapist the retraining of sensibility after peripheral nerve repair is an important part of peripheral nerve injury rehabilitation. This is because sensibility supports our ability to perform tasks efficiently and help fulfil our occupational roles.

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Intervention-Sensory re-education as an essential feature of rehabilitation following a peripheral nerve injury and repair in the hand/ upper limb.

Sensory re-education after nerve repair refer to: " The gradual and progressive process of reprogramming the brain through the use of cognitive learning techniques such as visualization and verbalization, the use of alternative senses such as vision or hearing and the use of graded tactile stimuli designed to maintain and/ or restore sensory areas affected by nerve injury.

" (C., 2011)

In order to reactivate the somatosensory cortex and to reserve the cortical representation of the hand and indirectly facilitate better functionality. (Paula MH, 2016) A sensory re-education programme should be put into place. A sensory re-education programme has exercises that re-educate and train the patient who has a nerve injury, to be able to accurately interpret stimuli from the environment.

There are two phases and each phase of the nerve recovery process have specific exercises that need to be followed. The sensory re-education treatment usually starts six to eight months after the nerve has been repaired. Theses exercises need to be done two to four times per day for ten minutes. Re-evaluation must be done in the first, third and sixth months to allow for object recognition, texture and correct localisation. (Pedretti. L.W, 2013)

Sensory re-education Phase 1

This period from nerve repair to nerve injury with no or scarce sensibility in the hand is acknowledged as Phase 1 of sensory re-education. The hand-map in the brain has vanished. This phase lasts up to three months after injury at wrist level and includes the time frame from after surgery to when some growing axons have reached the palm of the hand.

This phase has no protective sensation therefore the goal of this phase is to prevent any injury to the hand. It is also important to observe the hand when in use so that you can avoid injuries to the skin. The goal of this phase is also to stimulate and preserve the affected cortical hand map by maintaining mobility in the hand. Therefore, this makes re-learning easier once the axons have regrown and have reached the palm of the hand. Then sensation starts to return. Activating and retraining in the cortical map is done by giving the brain an illusion of feeling in the hand. (Rosen, 2006)

The training:

Observing others touching stuff, wonder how such objects usually feels. By touching the sections in the hand that have no sensation in amalgamation with intense watching, this causes the activation of the hand map. Repetition should occur several times per day. For example, you can allow someone to touch the both the unaffected and affected hands at the same time while you watch attentively and concentrate on the sensation. A mirror is another way that can be used.

It must be positioned in the body's midline, so you can watch the unaffected hand move, feel and manipulate objects in the mirror creating an illusion to like the injured hand. This creates an illusion that allows the brain to think that there is activity in the injured hand. Another example is to also use other senses to substitute for the absence of sensation phase 1. An example of this would be to closely hear the sound of the manipulation by the affected hand of a rough object. (Rosen, 2006)

Sensory re-education Phase 2

Phase 2 of sensory re-training starts when the axons of the repaired nerve have reached the palm. Therefore, the hand has sensation in the palm. This means that sensation has reached the hand and the hand map has changed pattern in the brain. The goal of this phase is to re-organise the cortical hand-map and to re-learn the ability to interpret the sensory input accurately. (Rosen, 2006)

The training:

Localise touch by touching an area with sensation that is affected by using a blunt object. Move or press the object hard enough for you to notice the sensory input. Compare this sensation to an unaffected area where you normally would have sensation. Concentrate on Where, What and How the sensory input is perceived.

Try to complete the above with the use of vision and then do it without vision by concentrating on the location and nature you feel the touch. Is it in the area where you touch or somewhere else? Is it static or moving touch? Does it feel different from the area with normal sensibility? Repeat the touch, first with your eyes open and then with your eyes closed until you feel you know the location and character of the touch.

Sensory re-education is well established as a therapeutic modality for nerve repair, however its main limitation is that is can not be used as part of early phase retraining with sensory replacement as no re-innervation has occurred. (Paula MH, 2016)