Ischemic Monomelic Neuropathy Treatment & Management

Updated: Jan 17, 2019
  • Author: Michael T Andary, MD, MS; Chief Editor: Dean H Hommer, MD  more...
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Treatment

Approach Considerations

Few predictable medical problems are associated with ischemic monomelic neuropathy (IMN). Evaluation by a physiatrist can help in the diagnosis, treatment, and rehabilitation of the condition.

Surgery has little to offer in established IMN. In cases of acute thrombosis or compartment syndrome, surgical intervention may be beneficial. [1, 2] There is at least one case of IMN caused by an arteriovenous fistula for dialysis that improved with surgery. The fistula was banded and neurologic function returned; the graft was saved for future use in dialysis. [10]

A case study by Coscione et al indicates that in patients with suspected IMN, good treatment results may be obtained through urgent management. In the case report, a male aged 75 years received a left prosthetic brachial-axillary access and 11 weeks later was found to have gross swelling and function loss in the left arm. The patient suffered from central venous stenosis, with swelling secondary to recurrent central venous occlusion. The authors suggested that this affected arterial flow through the graft and thus nerve perfusion, resulting in IMN. Following urgent ligation of the brachial-axillary access, however, the arm regained function. This suggests that early surgical intervention may in some cases improve outcome. [11]

Inpatient and outpatient care

Inpatient care for patients with IMN is 2-fold. Patients with IMN may have numerous comorbid medical and surgical problems that require monitoring and interventions. If the IMN significantly interferes with wrist/hand or ankle/foot function, physical and occupational therapy services are warranted under the direction of physiatry specialists.

Outpatient care is a continuation of rehabilitation goals and may include functional mobility training, preservation of range of motion (ROM), education with regard to limb care, and pain management. Psychological counseling to assist with adjustment to disability also may be warranted.

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Physical and Occupational Therapy

Physical therapy

Rehabilitation measures to assist with recovery after IMN depend on the degree of nerve injury. An aggressive and appropriate ROM program can prevent contractures in the involved limb. Thermal agents should be used with caution, given concomitant sensory impairments. For gait activities, a double metal upright or solid plastic ankle-foot orthosis (AFO) may be indicated if there is poor control of ankle and foot movement.

In a study of two patients with IMN, Singh et al found that strength improved with rehabilitation therapy and that paresthesia vanished over time. IMN developed in the patients, both of whom had diabetes, after a left upper extremity brachiocephalic fistula was created, with the patients declining treatment with surgical litigation. Weakness was significantly reduced with rehabilitation therapy, while at 11-month follow-up, paresthesia was absent. The investigators suggested that the outcome of this study challenges the use of fistula ligation in such cases. [12]

Occupational therapy

An aggressive and appropriate ROM program, particularly for the hands, can prevent contractures. Working to improve activities of daily living (ADL) is important, and adaptive equipment may be beneficial in aiding independence.

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