What rehabilitation approach is recommended for a patient with a history of wrist drop, who can move all fingers when the forearm is at rest, but has limited motor agility in the wrist area and can only flex and extend the wrist when it is supported on a table?

Rehabilitation for Recovering Radial Nerve Injury with Persistent Wrist Motor Deficit

Your patient requires structured progressive resistance training combined with task-specific wrist exercises, with Functional Electrical Stimulation (FES) applied to the wrist and forearm extensors as an adjunctive therapy. 1, 2

Positive Prognostic Context

Your patient has already achieved significant motor recovery—resolution of wrist drop and preserved finger movement indicate favorable prognosis for continued improvement. 2 The presence of voluntary finger extension is a positive prognostic indicator for upper extremity motor recovery. 1, 2 However, the inability to actively extend or flex the wrist without table support represents incomplete recovery that will not spontaneously improve without structured intervention. 2

Primary Intervention: Progressive Resistance Training

Implement the following structured protocol as recommended by the American College of Rehabilitation Medicine: 1, 2

• Start with low-intensity resistance at 40% of 1-repetition maximum (1-RM) with 10-15 repetitions 1, 2
• Progress to moderate intensity (41-60% of 1-RM) with 8-10 repetitions as the patient tolerates 1, 2
• Perform resistance training 2-3 times per week to allow adequate recovery between sessions 1, 2
• Increase resistance when 15 repetitions become only somewhat difficult (Borg RPE 12-14) 3

Critical safety consideration: Do NOT progress resistance too quickly—start with very low intensity during initial sessions to avoid muscle damage, particularly given the history of denervation. 1, 2

Task-Specific Wrist Practice

The American Heart Association recommends intensive task-specific training focusing on wrist extension and flexion movements: 4

• Practice functional activities that progressively challenge wrist control with graded difficulty 4
• Ensure repetitive, goal-oriented movements that promote neural reorganization 3
• Progress from supported (table-based) to unsupported wrist movements as motor control improves 4
• Incorporate activities requiring normal movement patterns with good alignment during functional tasks 3

Adjunctive Therapy: Functional Electrical Stimulation

FES should be applied to the wrist and forearm extensor muscles as recommended by the World Stroke Organization and American Heart Association: 4

• FES is specifically beneficial for patients with demonstrated impaired muscle contraction and wrist motor impairment 1, 3
• Use FES in combination with task-specific training to enhance motor control and reduce motor impairment 4
• FES leads to short-term increases in motor strength and motor control by providing sensory input and facilitating more complete muscle contractions 1, 3
• Apply FES as an adjunct to motor practice, not as standalone treatment 3

Flexibility Training Component

Implement flexibility exercises alongside resistance work: 1, 2

• Perform static stretches held for 10-30 seconds with 3-4 repetitions for each stretch 1, 2
• Continue flexibility training 2-3 times per week in conjunction with resistance work 1, 2

Critical Management Principles: What NOT to Do

The American Academy of Physical Medicine and Rehabilitation and American Physical Therapy Association provide clear contraindications: 2, 3

• Do NOT use splinting or immobilization—this prevents restoration of normal movement and function 1, 2, 3
• Avoid prolonged positioning of the wrist at end ranges—this exacerbates symptoms and may impede recovery 1, 2, 3
• Do not rely on passive range of motion alone—active motor practice is essential 4

Expected Timeline and Duration

Continue this structured rehabilitation program for 9-12 months depending on return-to-work goals for optimal functional recovery. 1, 2 The American College of Rehabilitation Medicine indicates that rapid relief of symptoms typically occurs within 3-4 months with structured rehabilitation, with maintenance of gains over 12 months. 2 Most motor recovery gains occur within the first 6 months, making this a critical window for intensive rehabilitation. 2

Common Pitfall to Avoid

The absence of active wrist motor function outside of supported positions represents incomplete recovery that will not spontaneously improve without structured resistance training and task-specific practice. 2 Many clinicians mistakenly assume that resolution of wrist drop indicates complete recovery, but persistent motor deficits require targeted intervention as outlined above.