What is the recommended approach for rehabilitation of a brachial plexus injury?

Rehabilitation of Brachial Plexus Injury

Rehabilitation should be implemented across all recovery phases—spontaneous recovery, postoperative, and sequelae periods—with a comprehensive program centered on kinesiotherapy (range of motion, stretching, strengthening), sensory re-education, and electrotherapy modalities. 1, 2

Core Rehabilitation Components

Exercise Therapy (Kinesiotherapy)

• Range of motion exercises are the most fundamental intervention to prevent contractures and maintain joint mobility during nerve regeneration 2, 3
• Muscle stretching prevents soft tissue shortening and maintains flexibility in denervated muscles 2
• Progressive strengthening exercises should be initiated as reinnervation occurs, guided by clinical and electromyographic evidence of muscle recovery 2, 3
• For Parsonage-Turner syndrome specifically, physical therapy focuses on maintaining range of motion while monitoring for spontaneous recovery 4

Sensory Re-education

• Sensory training is critical for functional recovery and should be incorporated throughout rehabilitation 1, 2
• This addresses the sensory deficits that accompany motor impairment in brachial plexus injuries 1

Electrotherapy Modalities

• Transcutaneous electrical nerve stimulation (TENS) combined with mid-frequency electrotherapy demonstrates superior outcomes compared to home-based electrical stimulation alone 3
• Neuroelectromagnetic stimulation has been studied as an adjunctive modality 1
• Comprehensive rehabilitation including TENS and mid-frequency therapy shows earlier appearance of regeneration potentials on EMG compared to non-integrated approaches 3

Evidence-Based Rehabilitation Protocol

Treatment Intensity and Duration

• Comprehensive rehabilitation (TENS, mid-frequency electrotherapy, manual therapy, occupational therapy) delivered in 30-day courses shows significant functional improvement after four courses 3
• This integrated approach produces statistically significant improvements in both total and branch brachial plexus injuries (P < 0.01 for total injuries, P < 0.05 for branch injuries) 3

Additional Modalities

• Manual therapy (Tuina therapy) combined with other interventions enhances outcomes 3
• Occupational therapy is essential throughout all phases for functional task training 3
• Acupuncture and massage therapy have been studied but require further validation 1
• Phototherapy and hydrotherapy are less studied but may have adjunctive roles 1

Phase-Specific Considerations

Spontaneous Recovery Period

• Initiate passive range of motion immediately to prevent contractures 1
• Apply electrical stimulation to maintain muscle viability during denervation 3
• Begin sensory re-education as tolerated 1, 2

Postoperative Period

• Address postoperative edema and pain management, which are often neglected 1
• Continue protective range of motion per surgical protocol 1
• Progress to active-assisted exercises as nerve regeneration permits 2

Sequelae Period

• Focus on compensatory strategies and adaptive techniques 1
• Consider tendon transfers or free functional muscle transfers if nerve recovery plateaus 5, 6
• Maintain long-term therapy engagement given the prolonged recovery timeline (often 12-24 months) 6

Critical Pitfalls to Avoid

The most significant limitation in current practice is the lack of standardized treatment parameters and protocols, making reproducibility challenging 2. Most studies demonstrate low levels of evidence, creating gaps in optimal dosing, frequency, and duration of specific interventions 2.

Neonatal brachial plexus injuries require specialized protocols that differ from adult rehabilitation but are frequently overlooked in standard approaches 1.

Surgical timing is critical: when treated within 6 months, outcomes for shoulder and elbow function are favorable, but delayed treatment significantly compromises results 6. Rehabilitation must be coordinated with this surgical window.

Hand function restoration remains the most challenging aspect of complete brachial plexus injury rehabilitation, with limited recovery even with optimal treatment 6.