What is the best course of treatment for a patient with no pain, good extension of the wrist and fingers, and the ability to wave their hand back and forth using the remaining strength in their wrist?

Management of Recovering Nerve Injury with Preserved Wrist/Finger Extension

This patient requires intensive task-specific rehabilitation with resistance training and functional electrical stimulation, not splinting or passive observation, as the presence of voluntary wrist and finger extension indicates significant motor recovery has occurred but persistent weakness will not spontaneously improve without structured intervention. 1, 2

Positive Prognostic Context

• Resolution of wrist drop with maintained finger extension represents a favorable recovery trajectory, as voluntary finger extension is a positive prognostic indicator for upper extremity motor recovery 1, 2
• The absence of pain is advantageous, as it allows for more aggressive rehabilitation without symptom exacerbation 3
• However, the described "remaining strength" for wrist movement indicates incomplete recovery that requires active intervention 1

Primary Treatment: Task-Specific Practice Protocol

Implement intensive task-specific training focusing on wrist extension/flexion movements and functional activities that progressively challenge wrist control with graded difficulty. 1, 2

• Begin with supported (table-based) wrist movements and progress to unsupported movements as motor control improves 1
• Incorporate repetitive, goal-oriented functional activities requiring active wrist use with normal movement patterns and good alignment 2
• Gradually increase resistance and complexity as the wrist demonstrates improved control 2
• Practice functional activities that require normal movement patterns with even weight distribution during tasks 2

Adjunctive Therapy: Functional Electrical Stimulation

Apply FES to the wrist and forearm extensor muscles as an adjunct to motor practice, not as standalone treatment. 1, 2

• FES is specifically beneficial for patients with demonstrated impaired muscle contraction and wrist motor impairment 1, 2
• Use FES in combination with task-specific training to enhance motor control and reduce motor impairment 1
• FES promotes neural reorganization by providing sensory input and facilitating more complete muscle contractions 2
• Historical evidence supports that automated positional feedback with electrical stimulation produces significant gains in wrist extension torque (280% increase) and selective range of motion (200% gain) 4

Resistance Training Prescription

Begin with low-intensity resistance at 40% of 1-repetition maximum with 10-15 repetitions. 1, 2

• Progress to moderate intensity (41-60% of 1-RM) with 8-10 repetitions as tolerated 1, 2
• Increase resistance when 15 repetitions become only somewhat difficult (Borg RPE 12-14) 2
• Perform resistance training 2-3 times per week to allow adequate recovery between sessions 1
• Do not progress resistance too quickly—start with very low intensity during initial sessions to avoid muscle damage 1

Flexibility Training Component

Implement 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
• This maintains range of motion while building strength 2

Critical Management Principles: What NOT to Do

Do not use splinting, as it prevents restoration of normal movement and function and may promote learned non-use. 1, 2

• Avoid prolonged positioning of the wrist at end ranges, which exacerbates symptoms and may impede recovery 1, 2
• Do not rely on passive range of motion alone—active motor practice is essential 1
• Avoid one-on-one passive therapy when automated equipment or home programs can provide controlled repetitive exercise 4

Expected Timeline and Duration

Continue rehabilitation for 9-12 months depending on functional and return-to-work goals for optimal recovery. 1, 2

• Most motor recovery gains occur within the first 6 months, making this a critical window for intensive rehabilitation 1
• Rapid relief of symptoms typically occurs within 3-4 months with structured rehabilitation, with maintenance of gains over 12 months 1
• The absence of motor function outside extension represents incomplete recovery that will not spontaneously improve without structured resistance training and task-specific practice 1

Monitoring Requirements

Monitor for any development of unremitting pain during follow-up, which would warrant reevaluation. 3, 2

• Reassess functional progress using validated outcome measures such as the DASH or Patient-Rated Wrist Hand Evaluation (PRWHE) 5, 6
• The presence of continued voluntary finger extension throughout treatment confirms positive trajectory 1, 2