Brachial plexus injury (BPI) refers to damage to the network of nerves (the brachial plexus). This network is responsible for motor and sensory functions of the upper limb. Injuries to the brachial plexus can result in a range of symptoms and can vary in severity from mild, temporary sensory changes to severe, permanent motor and sensory deficits.
Brachial plexus injury is very commonly associated with motor vehicle accident. Other reasons can be due to fall, stab wounds or birth injuries.
In the past decade, nerve transfers have become the mainstay of the treatment in upper brachial plexus injuries.
The priorities in the adult brachial plexus injury reconstruction are return of elbow function followed by shoulder recovery and stabilisation.
Nerve transfer or neurotization is a surgical procedure used to restore function in cases of brachial plexus injuries. This procedure involves using a healthy donor nerve to reinnervate a denervated muscle or group of muscles. A donor nerve is sacrificed and sutured to the distal end of the recipient nerve.
For example – the SAN (Spinal Accessory Nerve) to SSN (Suprascapular nerve) transfer is commonly used in upper brachial plexus injury. This transfer helps in restoration of shoulder function, as injury to upper trunk of brachial plexus results in the loss of elbow flexion along with shoulder abduction/external rotation.
Managing a brachial plexus injury (BPI) after neurotisation (nerve transfer surgery) involves a comprehensive and individualised physiotherapy programme aimed at restoring function, strength, and mobility. Here’s a structured approach to physiotherapy management in such cases:
1. Post-Operative Phase (Immediate to 6 Weeks)
Objective is to protect the surgical repair & minimise pain and swelling. Also to prevent joint stiffness and muscle atrophy.
Interventions:
● Immobilization: The limb is often immobilized in a protective position for 3-6 weeks post-surgery.
● Pain Management: Use of pain medications, modalities like TENS, and cryotherapy.
● Edema Control: Elevation, compression garments, and gentle massage.
● Passive Range of Motion (PROM): Gentle PROM exercises for joints distal to the immobilised area to prevent stiffness.
● Patient Education: Educating the patient about activity restrictions and the importance of protecting the surgical site.
2. Early Rehabilitation Phase (6 Weeks to 3 Months)
Objective is to Gradually restore mobility. Begin reactivation of transferred nerves and target muscles. Prevent compensatory movement patterns.
Interventions:
● Active-Assisted Range of Motion (AAROM): Initiate AAROM exercises as per surgeon’s advice.
● Muscle Re-education: Use electrical stimulation to facilitate muscle contraction in reinnervated muscles.
● Neuromuscular Re-education: Focus on activating the transferred nerve and its new muscle targets with exercises.
● Gentle Strengthening: Start with isometric exercises progressing to isotonic as tolerated.
3. Intermediate Rehabilitation Phase (3 to 6 Months)
Objective- Increase strength and endurance of reinnervated muscles. Enhance functional use of the arm and hand.
Interventions:
● Progressive Resistive Exercises: Gradual increase in resistance and intensity of exercises to build strength.
● Functional Training: Incorporate task-specific training to improve daily activities.
● Scapular Stabilisation: Strengthen the scapular muscles to ensure proper shoulder mechanics.
● Range of Motion Exercises: Continue AAROM and AROM to maintain joint mobility.
4. Advanced Rehabilitation Phase (6 Months to 1 Year)
Objective- Optimize functional recovery. Achieve near-normal strength and range of motion. Enhance coordination and fine motor skills.
Interventions:
● Advanced Strengthening: Use of heavier resistance, weight training, and functional resistance exercises.
● Plyometrics and Dynamic Exercises: For high-level functional activities and sports.
● Fine Motor Skills Training: Incorporate dexterity exercises for hand and fingers.
● Comprehensive Functional Training: Focus on work or sport-specific activities and tasks.
5. Long-Term Management (Beyond 1 Year)
Objective – Maintain gains in strength and function. Address any residual deficits and prevent overuse injuries.
Interventions:
● Maintenance Exercises: Continue a home exercise program to sustain muscle strength and joint flexibility.
● Periodic Re-evaluation: Regular check-ups with the physiotherapist to adjust the programme as needed.
● Ergonomic Advice: Guidance on modifications to work or daily activities to avoid overuse injuries.
Conclusively, recovery may take unto 2 years, hence, patience and persistence is required on patient’s part. Moreover, by following these structured phases and interventions, physiotherapy can play a crucial role in maximizing functional recovery after neurotisation for brachial plexus injuries.
Harpreet Kaur is a physiotherapist, sports exercise specialist, corrective exercise specialist & REPS certified fitness coach. With 15 years of experience in the health industry, she recently started as an entrepreneur, with a goal to educate the community about exercise connection with human body. See more at https://fitwithpreet.com
