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5 Exercises to Heal Spinal Accessory Nerve Damage скачать в хорошем качестве

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5 Exercises to Heal Spinal Accessory Nerve Damage
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5 Exercises to Heal Spinal Accessory Nerve Damage

The spinal accessory nerve, cranial nerve XI, provides motor innervation to the sternocleidomastoid (SCM) and upper trapezius muscles. The functions of these muscles include; contralateral head rotation (SCM), ipsilateral head flexion (SCM), neck flexion (bilateral SCM), shoulder elevation (trapezius), and cervical extension (bilateral trapezius). (1)  The spinal accessory nerve begins in the upper spinal cord, then briefly enters the cranium through the foramen magnum before exiting through the jugular foramen. The nerve courses caudally to innervate the SCM, then pierces that muscle 5cm below the mastoid and continues obliquely down through the posterior triangle on the surface of the levator muscle to innervate the trapezius. (2) The nerve has a long and superficial course through the posterior cervical region, where it is vulnerable to injury. (3)  The most frequent causes of injury to the spinal accessory nerve include blunt trauma (sports injury, whiplash, etc.), penetrating injury (stab, gun shot), or surgery (lymph node biopsy, neck dissection, carotid endarterectomy) (4-8) The condition is so common following neck surgery that the term “shoulder syndrome” has been coined to describe the associated pain and dysfunction. (4)  Spinal accessory nerve injury generally causes neck pain that radiates toward the interscapular region and occasionally, the ipsilateral arm. Symptoms often worsen when the arm is in a dependent position. Symptoms may intensify when the spinal accessory nerve is stretched via contralateral head rotation and ipsilateral shoulder depression. (2) Myofascial pain commonly accompanies spinal accessory nerve injury, secondary to chronic traction strain on the rhomboid and levator. (8) Chronic spinal accessory nerve deficits may lead to sternoclavicular joint pain secondary to the associated biomechanical stresses. (9) The most common complaint of spinal accessory nerve injury is fatigue and/or limited function when performing overhead activities. Trapezius denervation often results in shoulder girdle depression (i.e. shoulder droop), atrophy and difficulty performing shoulder shrugs. (4) Trapezius weakness and/or atrophy may lead to scapular winging that is accentuated by resisted abduction and/or external rotation. In contrast, scapular winging that results from long thoracic nerve injury is typically accentuated during resisted forward flexion. (8) Patients with spinal accessory nerve dysfunction often demonstrate a positive Scapular Flip Sign, i.e. increased scapular winging on resisted external rotation with the arm at the side, elbow flexed to 90 degrees. (10,11)  Conservative care is indicated in patients with tolerable symptoms and minimal dysfunction that is improving as evidenced by EMG and clinical assessment. (12) Studies suggest that early, aggressive, and prolonged conservative therapy is effective. (12-14) A primary goal of treatment is to prevent loss of shoulder mobility (i.e. adhesive capsulitis) while the nerve heals. (12,15)  Specific exercises include; passive shoulder internal rotation with the hand behind the back, shoulder external rotation with the elbow flexed to 90 degrees at the side, and passive shoulder forward elevation in a scapular plane, or with the hands clasped together. (16) Passive forward elevation may be performed in supine and half sitting positions. Strengthening the scapula stabilizers (i.e. serratus anterior and lower trapezius) has been shown to improve function, particularly shoulder abduction. (14,16) Patients should avoid carrying heavy weights on the shoulder (i.e. purse, backpack, etc). Patients may further decrease traction strain on the trapezius by hooking their thumb in their pants pocket. (16) The use of a sling can provide symptomatic relief; however, long-term use may be counterproductive. Palliative anti-inflammatory therapy modalities and NSAID’s may provide short-term benefit. (17)  Surgery should be considered for patients who fail one year of conservative management (19,20) and identified iatrogenic (i.e intra-operative injuries). (21) Surgical interventions include nerve repair, nerve grafting, neurolysis, or muscle transfer. (4)

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