Review of rehabilitation protocols for brachial plexus injury

Resting-state brain network remodeling after different nerve reconstruction surgeries: a functional magnetic resonance imaging study in brachial plexus injury rats

JOURNAL/nrgr/04.03/01300535-202505000-00031/figure1/v/2024-07-28T173839Z/r/image-tiff Distinct brain remodeling has been found after different nerve reconstruction strategies, including motor representation of the affected limb. However, differences among reconstruction strategies at the brain network level have not been elucidated. This study aimed to explore intra-network changes related to altered peripheral neural pathways after different nerve reconstruction surgeries, including nerve repair, end-to-end nerve transfer, and end-to-side nerve transfer. Sprague-Dawley rats underwent complete left brachial plexus transection and were divided into four equal groups of eight: no nerve repair, grafted nerve repair, phrenic nerve end-to-end transfer, and end-to-side transfer with a graft sutured to the anterior upper trunk. Resting-state brain functional magnetic resonance imaging was obtained 7 months after surgery. The independent component analysis algorithm was utilized to identify group-level network components of interest and extract resting-state functional connectivity values of each voxel within the component. Alterations in intra-network resting-state functional connectivity were compared among the groups. Target muscle reinnervation was assessed by behavioral observation (elbow flexion) and electromyography. The results showed that alterations in the sensorimotor and interoception networks were mostly related to changes in the peripheral neural pathway. Nerve repair was related to enhanced connectivity within the sensorimotor network, while end-to-side nerve transfer might be more beneficial for restoring control over the affected limb by the original motor representation. The thalamic-cortical pathway was enhanced within the interoception network after nerve repair and end-to-end nerve transfer. Brain areas related to cognition and emotion were enhanced after end-to-side nerve transfer. Our study revealed important brain networks related to different nerve reconstructions. These networks may be potential targets for enhancing motor recovery.

Brachial Plexus Neuropraxia Post Open Reduction and Internal Fixation of Left Acetabulum Fracture

Introduction

Acetabular fractures are often sustained injuries linked to high-energy trauma, such as falls from a considerable height or road traffic incidents. The modified Stoppa technique is currently used approach to treat acetabular fractures. The brachial plexus injury following open reduction and internal fixation (ORIF) of the left acetabulum fracture wasn't reported before.

Case Report

Herein we presented a case of a 16-years-old male with a history of road traffic accident sustained an isolated close left acetabulum fracture. X-ray shows associated both column acetabulum fracture with central subluxation. He was managed with open reduction and internal fixation through a modified Stoppa approach with a lateral window. The patient underwent ORIF on the 6th day of the trauma. Fixation was done with plates and screws. At recovery room he could not move whole left upper limb and no sensation while the operated limb DNV was intact. After 15 min of recovery, sensation returned, but motor deficit persisted, indicating brachial plexus neuropraxia. The brain CT scan of was performed and unremarkable finding. After 6 months, the patient restores his sensation on his own, and improved power 5/5 of the left upper limb.

Conclusion

Long stays under general anesthesia and patient position are considerable causes of BPI. Early diagnosis (clinical/imaging) and management typically involve conservative measures, with most patients achieving full recovery. Prevention procedures are essential, including monitoring the patient and proper intraoperative positioning to avoid such nerve injury.

Modern Medical Rehabilitation Methods for Patients with Peripheral Nerve and Brachial Plexus Injuries (Review)

Peripheral nerve and brachial plexus injuries represent one of the most serious medical challenges due to the high frequency of disabling consequences. Medical rehabilitation for such injuries is critically important as it ensures the most complete functional recovery for patients. The aim of this review is to summarize and interpret the data on medical rehabilitation methods, as well as to assess the effectiveness of rehabilitation strategies and techniques for restoring upper limb functions after peripheral nerve and brachial plexus injuries. Information is provided on the theoretical foundations of functional recovery following peripheral nerve and nerve plexus injuries, as well as on factors that may hinder the full functional recovery of patients. There are discussed rehabilitation strategies and methods aimed at accelerating nerve fiber regeneration, preventing complications, correcting cortical plasticity, restoring patients' functional capabilities, and improving their quality of life. Special attention is given to pain management, electrical stimulation, sensory deficit correction, and physical therapy in the postoperative period. Rehabilitation modalities and the medical rehabilitation duration are highly individualized and depend on numerous factors that determine the rehabilitation interventions direction. However, a significant number of rehabilitation methods have a low evidence base: many scientific studies are based on small samples, do not consider the heterogeneous nature of injuries, and do not evaluate longterm outcomes. Further research is needed to assess the effectiveness of both individual rehabilitation techniques and comprehensive rehabilitation programs that facilitate the recovery of motor activity in patients with peripheral nerve and brachial plexus injuries.

Functional outcomes following nerve transfers for shoulder and elbow reanimation in brachial plexus injuries: a 10-year retrospective study

Brachial plexus injuries are rare but highly disabling, with major implications for upper limb function and quality of life. Nerve transfers have emerged as a key reconstructive technique, particularly valuable in cases where primary repair or grafting is unfeasible or delayed. This retrospective study analysed functional outcomes following nerve transfers in 37 patients with brachial plexus injury. Motor recovery was assessed using the Medical Research Council scale. Patients were stratified by age, timing of surgery, injury severity, and type of nerve transfer performed. The majority of our cohort consisted of male adults, predominantly injured in motorcycle accidents, while pediatric cases were mostly due to obstetrical trauma. For shoulder reanimation, all patients received spinal accessory to suprascapular nerve transfer, with a subset also undergoing medial triceps branch of the radial nerve to axillary nerve transfer. These techniques resulted in 85.3% of patients achieving shoulder function recovery with M3 or M4 muscle strength, with combined procedures leading exclusively to M3 or M4 muscle strength. For elbow flexion restoration, surgical approaches included intercostal to musculocutaneous nerve transfer, ulnar and median fascicles to musculocutaneous nerve transfer, contralateral C7 to musculocutaneous nerve transfer with ulnar graft, and spinal accessory to musculocutaneous nerve transfer with sural nerve graft. Root grafting procedures using sural nerve grafts or nerve conduits were employed in three pediatric patients. Overall, 84.38% of patients achieved elbow flexion recovery with M3 or M4 muscle strength. These findings reinforce the utility of nerve transfers as a cornerstone in the surgical management of brachial plexus injury.

Experimental Biomechanics of Neonatal Brachial Plexus Avulsion Injuries Using a Piglet Model

BACKGROUND

A brachial plexus avulsion occurs when the nerve root separates from the spinal cord during birthing trauma, such as shoulder dystocia or a difficult vaginal delivery. A complete paralysis of the affected levels occurs post-brachial plexus avulsion. Despite being reported in 10-20% of brachial plexus birthing injuries, it remains poorly diagnosed during the acute stages of injury, leading to poor intervention approaches. The poor diagnosis of brachial plexus avulsion injury can be attributed to the currently unavailable biomechanics of brachial plexus avulsion. While the biomechanical properties of neonatal brachial plexus are available, the forces required to avulse a neonatal brachial plexus remain unknown.

METHODS

This study aims to provide detailed biomechanics of the required forces and corresponding strains for neonatal brachial plexus avulsion. Biomechanical tensile testing was performed on an isolated, clinically relevant piglet spinal cord and brachial plexus complex, and the required avulsion forces and strains were measured.

RESULTS

The reported failure forces and corresponding strains were 3.9 ± 1.6 N at a 27.9 ± 6.5% strain, respectively.

CONCLUSION

The obtained data are required to understand the avulsion injury biomechanics and provide the necessary experimental data for computational model development that serves as an ideal surrogate for understanding complicated birthing injuries in newborns.

A fight on your own - experiences of rehabilitation after traumatic brachial plexus injuries

PURPOSE

Individuals with traumatic brachial plexus injuries (TBPI) may experience lifelong physical and psychosocial consequences. With or without surgical treatment, the rehabilitation is considered important. Physiotherapists and occupational therapists face challenges due to the scarcity of evidence-based rehabilitation protocols after TBPI. There is limited knowledge about patients' experiences with rehabilitation. This study aims to explore and describe patients' experiences of rehabilitation after a TBPI.

METHOD

Transcripts from five focus groups with 21 participants after TBPI and rehabilitation were coded and analysed with a qualitative content analysis. The discussion guide contained questions regarding experience of rehabilitation.

RESULTS

The analysis revealed one overarching theme: "A fight on your own", and three themes that include 1) Lack of tailored rehabilitation in a life-changing situation, 2) Crucial prerequisites for engagement in rehabilitation, and 3) Life will never be the same. The results highlighted the importance of healthcare professionals engaging with patients and advocates for comprehensive, person-centred rehabilitation programs across healthcare levels. Furthermore, participants value peer interaction, psychosocial support and up-to-date technology.

CONCLUSION

Patients struggle to access person-centred rehabilitation from engaged and knowledgeable occupational and physiotherapists. Addressing both psychosocial and physical aspects and daily activities is crucial.

Early Conservative Physical Therapy Management of Babies With Obstetric Brachial Plexus Injury to Facilitate Spontaneous Recovery

OBJECTIVE

To evaluate the effect of early immobilization and proper handling techniques in infants with Obstetric Brachial Plexus Injury (OBPI) in the first 2 weeks of life.

METHOD

Six 1-day-old infants (2 males and 4 females) with OBPI were included. The assessments were done at baseline, post-intervention, and 3-month follow-up, which involved a physical exam, Narakas classification, Active Movement Scale, and gross and fine motor skills evaluation.

RESULT

All infants had upper Erb's palsy. They had statistically significant improvement in the Active Movement Scale scores post-intervention with a large effect size. These improvements were maintained at follow-up. All infants achieved age-appropriate gross and fine motor skills with the affected upper limb at 3 months of age.

CONCLUSION

Early conservative physical therapy management had a statistically significant effect on enhancing spontaneous recovery and preventing further nerve injury in OBPI infants.

Obstetric Brachial Plexus Palsy and Functional Implications: Which Joint in the Upper Extremity Is More Closely Associated?

Background and Objectives: The objective of this study is to examine the correlation between the active range of motion (ROM) of the affected upper extremity and functional capacity in children with Obstetric Brachial Plexus Palsy (OBPP) who have undergone the modified Hoffer tendon transfer technique. Materials and Methods: The study cohort comprised 52 children with OBPP, aged 4-14 years, who had undergone a shoulder tendon transfer. The ROM was quantified using a goniometer, while functionality was evaluated through the administration of the Brachial Plexus Outcome Measure (BPOM). Results: The study identified significant correlations between the shoulder ROM and the Brachial Plexus Outcome Measure (BPOM). Specifically, shoulder flexion (p = 0.017; r = 0.351) was positively associated with shoulder functionality, while shoulder internal rotation (p = 0.001; r = 0.481) was linked to appearance scores. A significant negative relationship was observed between elbow extension (p < 0.001; r = -0.512) and elbow and forearm activities. Conclusions: The study highlights the necessity of assessing both joint range of motion and body perception for effective treatment and follow-up, to improve the functionality and quality of life for children with OBPP.

Long-Term Outcomes of Obstetric Brachial Plexus Injury: A Single-Center Experience

Obstetric brachial plexus injury (OBPI) is an important preventable complication of the birth process. While most cases recover in the early period, a substantial number result in sequelae. Despite established risk factors, there are cases that occur without any apparent risk factors. Our study aims to identify prenatal risk factors by examining OBPI cases born in our hospital and to provide insights into the prognosis of the disease by comparing cases with panplexopathy to those without. We included 31 cases followed for OBPI in our hospital. Risk factors related to the infant and the mother were investigated. The range of motion (ROM) measurements of the affected upper extremity joints, muscle strength, atrophy, and scoliosis status were evaluated. Of the cases, 71% were girls, and 61.3% had left-sided involvement. Additionally, 84.1% had risk factors, with oxytocin administration being the most frequently identified risk factor. In our study, we compared cases with panplexopathy to those without. Shoulder abduction, shoulder adduction, wrist flexion, and wrist extension restrictions were significantly more common in cases with panplexopathy. Furthermore, muscle atrophy was significantly more frequent in the panplexopathy group. Since OBPI is a preventable injury, identifying risk factors is crucial. However, there are conflicting results regarding the most significant risk factor. Our study highlights that oxytocin administration is a very important risk factor for OBPI. We found that cases with panplexopathy had a worse prognosis, with more frequent ROM limitations and muscle atrophy.

Quantitative Musculoskeletal Imaging of the Pediatric Shoulder

ABSTRACT

Pediatric acquired and congenital conditions leading to shoulder pain and dysfunction are common. Objective, quantitative musculoskeletal imaging-based measures of shoulder health in children lag recent developments in adults. We review promising applications of quantitative imaging that tend to be available for common pediatric shoulder pathologies, especially brachial plexus birth palsy and recurrent shoulder instability, and imaging-related considerations of musculoskeletal growth and development of the shoulder. We highlight the status of quantitative imaging practices for the pediatric shoulder and highlight gaps where better care may be provided with advances in imaging technique and/or technology.

Knowledge, attitudes, and practices of healthcare professionals toward rehabilitation of peripheral nerve injury

Peripheral nerve injury (PNI) occurs due to damage of peripheral nerves, with healthcare professionals playing significant roles in PNI rehabilitation. This study aimed to explore the knowledge, attitudes, and practices (KAP) towards PNI rehabilitation among healthcare professionals. This cross-sectional study was conducted on June 2023 in China and healthcare professionals were enrolled. A total of 611 valid questionnaires were collected, with 62.52% female respondents. Mean scores for KAP were 14.26 ± 2.044 (possible range: 0-19), 29.77 ± 3.622 (possible range: 7-35), and 41.55 ± 9.523 (possible range: 11-55), respectively. Multivariate logistic regression revealed positive associations of professional titles (OR = 1.743, 95% CI: 1.083-2.804), occupation (OR = 1.833, 95% CI: 1.151-2.919), and involvement in treatment or care of PNI patients (OR = 1.462, 95% CI: 1.024-2.088) with knowledge. Knowledge (OR = 1.155, 95% CI: 1.042-1.280), gender (OR = 2.140, 95% CI: 1.255-3.646), education (OR = 2.258, 95% CI: 1.131-4.507), and involvement in treatment or care of PNI patients (OR = 2.463, 95% CI: 1.460-4.155) were positively associated with attitude. Attitude (OR = 1.214, 95% CI: 1.148-1.283), bachelor's degree education (OR = 0.548, 95% CI: 0.326-0.919), master's degree or higher (OR = 0.545, 95% CI: 0.308-0.964), having rehabilitation training for PNI (OR = 2.485, 95% CI: 1.633-3.781), and involvement in treatment or care of PNI patients (OR = 2.093, 95% CI: 1.395-3.138) were independently associated with practice. Healthcare professionals exhibited moderate knowledge, positive attitudes, and moderate practices towards the PNI rehabilitation. Those involved in the treatment or care of PNI have significantly higher KAP. Targeted interventions were needed to enhance understanding and promote proactive engagement in clinical practice.

Brachial Plexus Injury Influences Efferent Transmission on More than Just the Symptomatic Side, as Verified with Clinical Neurophysiology Methods Using Magnetic and Electrical Stimulation

The variety of sources of brachial plexus injuries (BPIs) and the severity and similarity of their clinical symptoms with those of other injuries make their differential diagnosis difficult. Enriching their diagnosis with objective high-sensitivity diagnostics such as clinical neurophysiology may lead to satisfactory treatment results, and magnetic stimulation (MEP) might be an advantageous addition to the diagnostic standard of electrical stimulation used in electroneurography (ENG). The asymptomatic side in BPI cases sometimes shows only subclinical neurological deficits; this study aimed to clarify the validity and utility of using MEP vs. ENG to detect neural conduction abnormalities. Twenty patients with a BPI and twenty healthy volunteers with matching demographic and anthropometric characteristics were stimulated at their Erb's point in order to record the potentials evoked using magnetic and electrical stimuli to evaluate their peripheral motor neural transmission in their axillar, musculocutaneous, radial, and ulnar nerves. MEP was also used to verify the neural transmission in participants' cervical roots following transvertebral stimulations, checking the compatibility and repeatability of the evoked potential recordings. The clinical assessment resulted in an average muscle strength of 3-1 (with a mean of 2.2), analgesia that mainly manifested in the C5-C7 spinal dermatomes, and a pain evaluation of 6-4 (mean of 5.4) on the symptomatic side using the Visual Analog Scale, with no pathological symptoms on the contralateral side. A comparison of the recorded potentials evoked with magnetic versus electrical stimuli revealed that the MEP amplitudes were usually higher, at p = 0.04-0.03, in most of the healthy volunteers' recorded muscles than in those of the group of BPI patients, whose recordings showed that their CMAP and MEP amplitude values were lower on their more symptomatic than asymptomatic sides, at p = 0.04-0.009. In recordings following musculocutaneous and radial nerve electrical stimulation and ulnar nerve magnetic stimulation at Erb's point, the values of the latencies were also longer on the patient's asymptomatic side compared to those in the control group. The above outcomes prove the mixed axonal and demyelination natures of brachial plexus injuries. They indicate that different types of traumatic BPIs also involve the clinically asymptomatic side. Cases with predominantly median nerve lesions were detected in sensory nerve conduction studies (SNCSs). In 16 patients, electromyography revealed neurogenic damage to the deltoid and biceps muscles, with an active denervation process at work. The predominance of C5 and C6 brachial plexus injuries in the cervical root and upper/middle trunk of patients with BPI has been confirmed. A probable explanation for the bilateral symptoms of dysfunction detected via clinical neurophysiology methods in the examined BPI patients, who showed primarily unilateral damage, maybe the reaction of their internal neural spinal center's organization. Even when subclinical, this may explain the poor BPI treatment outcomes that sometimes occur following long-term physical therapy or surgical treatment.

Early post-surgical rehabilitation and functional outcomes of a traumatic ulnar nerve injury: a pediatric case report

Background

Peripheral nerve injuries (PNIs) of the upper limb are very common events within the pediatric population, especially following soft tissue trauma and bone fractures. Symptoms of brachial plexus nerve injuries can differ considerably depending on the site and severity of injury. Compared to median and radial nerves, the ulnar nerve (UN) is the most frequently and severely injured nerve of the upper extremity. Indeed, due to its peculiar anatomical path, the UN is known to be particularly vulnerable to traumatic injuries, which result in pain and substantial motor and sensory disabilities of the forearm and hand. Therefore, timely and appropriate postoperative management of UN lesions is crucial to avoid permanent sensorymotor deficits and claw hand deformities leading to lifelong impairments. Nevertheless, the literature regarding the rehabilitation following PNIs is limited and lacks clear evidence regarding a solid treatment algorithm for the management of UN lesions that ensures full functional recovery.

Case presentation

The patient is a 11-year-old child who experienced left-hand pain, stiffness, and disability secondary to a domestic accident. The traumatic UN lesion occurred about 8 cm proximal to Guyon's canal and it was surgically treated with termino-terminal (end-to-end) neurorrhaphy. One month after surgery, the patient underwent multimodal rehabilitative protocol and both subjective and functional measurements were recorded at baseline (T0) and at 3- (T1) and 5-month (T2) follow-up. At the end of the rehabilitation protocol, the patient achieved substantial reduction in pain and improvement in quality of life. Of considerable interest, the patient regained a complete functional recovery with satisfactory handgrip and pinch functions in addition with a decrease of disability in activities of daily living.

Conclusion

A timely and intensive rehabilitative intervention done by qualified hand therapist with previous training in the rehabilitation of upper limb neuromuscular disorders is pivotal to achieve a stable and optimal functional recovery of the hand, while preventing the onset of deformities, in patients with peripheral nerve injuries of the upper limb.

Evaluation and Diagnostic-Treatment Approaches of Brachial Plexus Injuries in Adults

Background

Brachial plexus injury (BPI), as one of the most devastating injuries in adults, has various negative consequences such as profound functional impairment, debilitating pain, significant mental health consequences, and economic impacts. We aimed to review the evaluation and diagnostic-treatment Approaches of BPI in adults through a review study.

Methods

An electronic literature search was completed in Google Scholar, Springer, PubMed, and Science Direct databases from 1980 to 2023. Various keywords related to the purpose such as Brachial plexus, surgical strategy, adult were used.

Results

1.2% of people with multiple traumas had BPIs. BPI is more common in young adult males. For brachial plexus palsy, preoperative evaluation of nerve root avulsion is helpful in surgical planning. . EMG is useful in confirming a diagnosis, localizing the lesion level, estimating the extent of axon loss, and determining whether the lesion is complete. There are different options available for BPI, such as coordinating care, rehabilitation and psychosocial support. In recent times, significant advancements have been made in surgical techniques for nerve repairs.

Conclusion

Although it is often not possible to prevent damage to the brachial plexus, it is possible to reduce the risk of further problems after the injury by taking some measures.

Functional Electrical Stimulation in Conjunction With Proprioceptive Neuromuscular Facilitation (PNF) Technique to Improve Upper Limb Function in Traumatic Brachial Plexus Injury: A Case Report

Traumatic brachial plexus injuries (TBPIs) in the adult population are primarily a result of road traffic accidents or falls on a shoulder, which mainly affects the young population. Adult TBPI is a serious incapacitating injury that affects young adults. It decreases the function of upper extremity muscles, which affects social participation and quality of life. Physiotherapy intervention demonstrates its effectiveness in enhancing and maintaining the function of the upper extremity, eventually decreasing the participation restriction and improving quality of life. The proprioceptive neuromuscular facilitation (PNF) technique has been selected as a useful therapeutic option to enhance upper limb function after TBPI. The preceding case report proved the effectiveness of six weeks of functional electrical stimulation in addition to the PNF technique in improving upper limb function after TBPI.