What is the role of physical therapy (PT) in the treatment of a spinal accessory nerve (SAN) injury?

Updated: Feb 09, 2018
  • Author: Rohan R Walvekar, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

PT is a crucial component of recovery from SAN injury and shoulder dysfunction. It is essential both for patients who decline or are ineligible for surgical intervention and for those who are planning to undergo surgical repair of the SAN.

The goal of PT is to maintain or regain passive ROM about the shoulder. This serves to limit or prevent stiffness of the shoulder capsule and ligaments that can arise with malalignment of the shoulder and adhesive capsulitis. A PT protocol as suggested by Salerno et al is described as follows: [4]

  • Passive forward elevation of the arm in the plane of the scapula in supine and half-sitting positions

  • Passive forward elevation with the hands locked in supine and half-sitting positions and subsequent stretching movements

  • External rotation with the elbow at the side and flexed at 90°

  • Internal rotation with the hand placed behind the back

The investigators assigned physical therapy to one study group (PT group) and compared that group’s findings with the findings of another group that did not undergo physical therapy (non-PT group). [4] All patients had undergone neck dissection with anatomic preservation of the SAN. A significant improvement in mobility, pain, quality of life, and return to previous occupation was seen in the PT group. Approximately 63% of the PT group, as compared with 10% of the non-PT group, was able to achieve what is known as the zero position: 165° flexion at the shoulder joint in a plane 45° anterior to the coronal plane. Achievement of this position is necessary for common daily activities.

Note that the benefits of PT were not evident 1 month after initiating therapy but were significant after 6 months of aggressive PT. [4] The authors of this study emphasized early and prolonged PT, beginning within 1 month of surgery and lasting, on average, 3 months. Optimally, PT should be instituted within 1 month surgery and continue for at least 3 months; however, recent literature suggests that PT is also effective for late-diagnosed SAN injury. [44]

A randomized, controlled trial by McGarvey et al suggested that scapular strengthening exercises following SAN injury in neck dissection can, at least in the short-term, maximize shoulder abduction. In the study, patients who had undergone neck dissection received either 12 weeks of progressive scapular strengthening exercises or usual care. At 3-month follow-up, carried out on 52 patients (53 shoulders), shoulder abduction in the PT group was greater than in the usual-care patients by a statistically significant amount (+26.6 degrees). [45]

Ultimately, if nonsurgical management of the shoulder syndrome is pursued, aggressive PT is vital to long-term preservation of shoulder function and reduction of pain. Serial clinical examinations and EMG monitoring is useful to monitor SAN function. However, with a dense, stable clinical and electrical neural deficit, early operative intervention yields the best results. [11]


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