Description of Intervention
Muscle movement requires nerve stimulation at the neuromuscular junction, contraction of muscle fibers, functional joints, and several other concurrent actions that ultimately produce movement. When one or more nerves of the upper extremity is damaged, nerve conduction is impaired, which reduces or eliminates stimulation at the neuromuscular junction and leads to movement-related deficits.1
Neuromuscular reeducation is a set of rehabilitation techniques used by hand therapists to treat patients with movement deficits from various injuries and conditions involving improper nerve and muscle functioning. These patients may consciously or subconsciously inhibit certain movements of the affected hand, wrist, or arm and often develop unhealthy movement behaviors as a result.2 Through a series of targeted interventions, the goals of neuromuscular reeducation are to help patients restore normal, controlled movement patterns, reduce their pain levels and optimize their joint biomechanics.2
Indications for Intervention
Neuromuscular control of the upper extremity can be impaired by any condition that affects the peripheral or central nervous system, such as neurologic diseases (e.g., stroke, cerebral palsy, hand dystonia), traumatic nerve injuries (e.g., brachial plexus injury, radial nerve injury, ulnar nerve injury), or severe musculoskeletal disorders (e.g., fibromyalgia, myofascial pain syndrome, complex regional pain syndrome [CRPS]).2,3 Patients recovering from certain surgeries of the upper extremity may also require neuromuscular reeducation.2
Diagnosis
- Ask the patient to describe their symptoms and medical history, including any neurologic diseases or recent injuries to the upper extremity.
- Perform a physical evaluation of the patient’s affected arm, wrist, and hand. Be sure to assess muscle strength, tone, and stretch reflexes, active and passive range of motion (ROM), and proprioception.
- Examine the contralateral arm, wrist, and hand for comparison.
- If additional diagnostic information is required, consider performing a nerve conduction study or electromyography (EMG) to assess the function of nerves and muscles.1
- Ask the patient if they have any comorbidities, including smoking, diabetes, or osteopenia.
- If the patient is returning for ongoing treatment, compare the current evaluation to assessments from prior visits.
Intervention Options
Hand therapists should take an individualized approach and design each neuromuscular reeducation program according to the patient’s specific movement deficits, functional abilities, and overall treatment goals.4 Most interventions involve repetitive movements, posturing, and forms of stimulation that are intended to reinforce the nerve signals of functional movements and ultimately make movement patterns become more automatic.4 Interventions that are typically featured in a neuromuscular reeducation program include the following1,3-5:
- Conscious neuromuscular exercises
- Isometric exercises
- Eccentric and concentric exercises
- Coactivation exercises
- Isokinetic exercises
- Unconscious neuromuscular exercises
- Reactive muscle activation exercises
- Electrical stimulation
- Functional electrical stimulation (FES)
- Transcutaneous electrical stimulation (TENS)
- Neuromuscular electrical stimulation (NMES)
- Learning-based sensorimotor training
- Orthotic devices / static and dynamic splinting to assist in proximal stability and/or positioning and stabilization at the same time.
The hand therapist should regularly monitor the patient’s progress throughout the reeducation program, paying close attention to changes in pain levels, swelling, ROM, proprioception, and overall movement patterns. As the patient improves, the intensity, frequency, and duration of the prescribed exercises should gradually increase according to the patient’s progress.4 During the course of therapy, splinting to allow proper positioning may be utilized for functional task simulation. Functional electric stimulation (FES) can be utilized to recruit muscle fibers and encourage the desired muscle action. For patients diagnosed with CRPS, desensitization techniques in addition to neuromuscular re-education can be utilized as a part of the therapists’ treatment plan. When using TENS with patients with CRPS, consider stimulating the contralateral side rather than the involved side.
Associated Diagnoses
- Stroke
- Cerebral palsy
- Nerve entrapment syndrome
- Brachial plexus, radial nerve, medial nerve, or ulnar nerve injury
- Focal dystonia
- Severe joint instability
- Myofascial pain syndrome
- CRPS
