SLR - August 2021 - Tehreem Sajjad

Impacts of Rehabilitation Gait Training on Functional Outcomes after Tibial Nerve Transfer for Patients with Peroneal Nerve Injury: A Non-Randomized Controlled Trail

Reference: Curran MWT, Morhart MJ, Olson JL, DeSerres JJ, Chan KM. Impacts of Rehabilitation Gait Training on Functional Outcomes after Tibial Nerve Transfer for Patients with Peroneal Nerve Injury: A Nonrandomized Controlled Trial. Plast Reconstr Surg. 2021 May 1;147(5):1202-1207. doi: 10.1097/PRS.0000000000007896. PMID: 33835089.

Level of Evidence: II

Scientific Literature Review

Reviewed By: Tehreem Sajjad, DPM
Residency Program: Beaumont Hospital - Farmington Hills, MI

Podiatric Relevancy: When drop foot is a result of a nerve injury, such as one to the common peroneal nerve, one treatment option is to restore the function of this nerve by performing a tibial nerve transfer. With this particular procedure, however, it’s important to understand that the post-operative course must include a period of rehabilitation gait training to allow for optimal functioning. Therefore, the authors of this study attempted to test the hypothesis that gait training would improve functional performance following a tibial nerve transfer due to foot drop as a result of a common peroneal nerve injury.

Methods:
Twenty patients were divided into two equal groups: surgery only (control) or surgery followed by gait training (treatment). Patients in the treatment group were offered biofeedback gait training, with the goal of maximizing electromyographic activity in the tibialis anterior muscle and minimizing activity in the plantarflexory muscles upon ankle dorsiflexion. Each patient was followed for two years and the Stanmore Scale (primary outcome measurement), the Medical Research Council Grade, and the quantitative force measure (secondary outcome measure) were used. 

Results: Patients who underwent rehabilitation gait training had a significantly higher Stanmore Scale scores (79.5 +/- 14.3) than patient in the control group (37.2 +/- 3.5). Medical Research Council Grades during bedside examination were 2.5 +/- 1.2 in the control group and 3.8 +/- 0.6 in the treatment group. Dorsiflexion strength was measured in patients with a Medical Research Council grade of 4 or above, all of which were in the gait training group.

Conclusions: The authors of this study concluded that rehabilitation gait training played an important role in improving functional outcomes in patients with foot drop with reinnervation following a tibial to peroneal nerve transfer. They did note as well that this is a non-randomized and unblinded study, and the results should thus be interpreted with caution. Distal nerve transfers in the upper limb have been successful in the past and post operatively generally include rehabilitation training. However, it has been noted that lower limb nerve transfers have been relatively unsuccessful and—of note—usually do not include any rehabilitation training protocols. As the authors mention, nerve transfer options in the lower extremity are limited as all muscles in the area are either innervated by the peroneal or tibial nerves and therefore a transfer involving these two nerves requires patients to learn to perform a completely opposite action, which is difficult to pursue as it demands a substantial amount of motor relearning. As a young physician, I think it’s paramount to keep this concept in mind during surgical planning to ensure patients maximize their outcomes postoperatively. 

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