Optimizing Outcomes After Nerve Transfer in a Global Pandemic
Jana Dengler, MASc, MD, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada, Kelly Bishop, MScOT, OT Reg. (Ont), Sunnybrook Health Sciences Centre, Toronto, ON, Canada and Christine B Novak, PT, PhD, Toronto Western Hospital Hand Program, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
Introduction
Upper extremity (UE) nerve transfer to restore motor function requires muscle reinnervation and establishment of new motor patterns. Optimal outcome depends on timely post-operative reassessment by the surgical and rehabilitation team, particularly following nerve transfer in spinal cord injury (SCI). Restrictions imposed by COVID-19 limited direct patient contact and disrupted normal scheduled care. We present a modified approach to post-operative care in a person with SCI after nerve transfer.
Material & Methods
To develop a modified care plan when direct patient contact is restricted, a retrospective case review was performed. The operative details, motor recovery and clinical follow-up times were retrieved from the medical records.
Results
A 26yo female sustained a C5-SCI in May 2019 and underwent UE nerve transfers (brachialis to AIN/FDS, supinator to PIN) in staged, bilateral procedures at 8 (left) and 9.5 (right) months post-injury. Clinical patient encounter restrictions necessitated virtual care for follow-up after nerve transfer and the opportunity to reassess more frequently and guide postoperative rehabilitation. Virtual follow-up assessments post-surgery first showed finger extension 2/5 at 4 months post-operatively (stronger with resisted supination), which increased to 3/5 at 6.5 months post-operatively and showed independent extension of the thumb, long and ring fingers without donor activation. Finger and thumb flexion of 1/5 was first seen at 4.5 months (with resisted elbow flexion), which increased to 2/5 by 6.5 months post-operatively. Early reinnervation of finger extensors (EDC) and finger flexors (FDS/FDP) was confirmed by in-person electromyography after new movement had been noted by virtual visit. The COVID-19 pandemic necessitated the development of educational tools that complemented virtual visits to train patients to self-monitor for early reinnervation after nerve transfers to allow for more accurate timing of recovery and optimize early rehabilitation.
Conclusions
Restrictions on direct patient care necessitated virtual follow-up visits and the opportunity to evaluate patients earlier than previously scheduled. Early muscle recovery following nerve transfer in the extensor muscles was observed at 4 months following surgery and in the finger and thumb flexors at 4.5 months following surgery. Using virtual care, patient education regarding exercises and progression of exercises were implemented. Virtual care offers a convenient opportunity for follow-up in this patient population. With virtual care, early progression of donor activation exercises is possible and may advance functional recovery.
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