What is the best course of treatment for a patient with weakness in dorsal movements, but preserved ventral movements, who can pinch and carry 10 pounds, and has some functional recovery?

Management of Dorsal-Sided Upper Extremity Weakness with Preserved Ventral Function

Initiate structured task-specific practice with resistance training as your primary intervention, supplemented with dynamic splinting that provides wrist and finger extension support through a tenodesis mechanism, while avoiding static immobilization. 1, 2

Immediate Splinting Strategy

• Use dynamic splinting that provides wrist and finger extension support through a tenodesis mechanism, not static immobilization. 2 This allows continued active movement while supporting the weak dorsal musculature.

• Avoid serial casting or prolonged static immobilization entirely, as this worsens symptoms, causes muscle deconditioning, promotes learned non-use, and can trigger complex regional pain syndrome. 3, 2 The evidence is clear that immobilization is contraindicated—strength loss is most dramatic during the first week of immobilization. 4

Core Rehabilitation Protocol

Task-Specific Functional Training

• Perform functional tasks that promote normal movement patterns with the affected hand, including using the hand to stabilize objects during activities, placing the hand on surfaces while standing (rather than letting it hang), and bilateral upper extremity tasks. 3, 1, 2

• Grade activities progressively to increase the time the affected hand is used within functional tasks, employing normal movement techniques and avoiding compensatory strategies that reinforce abnormal patterns. 2

• Engage in repetitive movement practice focusing on specific movements that address the lifting deficit, as motor practice can improve motor function both immediately and long after injury. 1

Resistance Training Protocol

Since you can carry 10 pounds but have dorsal weakness, implement a structured progression:

• Start resistance training 2-3 times per week at 40% of 1-repetition maximum with 10-15 repetitions. 1

• Progress to moderate intensity (41-60% of 1-RM) with 8-10 repetitions as tolerated. 1

• Do not progress resistance too quickly—start with very low intensity during initial sessions to avoid muscle damage. 1 This is a critical pitfall to avoid.

Adjunctive Interventions

Functional Electrical Stimulation

• Apply FES to the affected dorsal upper arm muscles as an adjunct to task-specific training, not as standalone treatment. 1, 2 Two systematic reviews including 46 studies (n=1900) concluded that neuromuscular electrical stimulation was effective in improving upper-limb motor impairment. 1

• FES is specifically beneficial for patients with demonstrated impaired muscle contraction, providing short-term increases in motor strength and control. 1, 2

Home Exercise Program

• Prescribe a directed home exercise program as the primary therapy modality, as evidence shows home programs are equivalent to supervised therapy for uncomplicated nerve palsy cases. 2

• Perform active finger motion exercises regularly, including stretching exercises for wrist flexors and extensors. 2

• Employ anxiety management and distraction techniques when undertaking tasks, as this can be helpful with all symptom types. 3, 4

Critical Management Principles

• Never rely on passive range of motion alone—active motor practice is essential. 1

• Avoid splinting that increases attention to the area, promotes accessory muscle use, or causes complete immobilization. 4, 2 This is a common pitfall that worsens outcomes.

• Discourage "nursing" of the affected limb but demonstrate and promote therapeutic resting postures and limb use. 3

Monitoring and Follow-Up

• Reassess function every 2-3 weeks to evaluate splint effectiveness, adjust therapy progression, and monitor for any adverse effects from splinting. 2

• Use video recording interventions (with consent) to demonstrate changeability in symptoms, highlight successes, and serve as reference points for replicating successful strategies. 2

Expected Recovery Timeline

• 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 appropriate structured rehabilitation, with maintenance of gains over 12 months. 1

• Optimal functional recovery requires 9-12 months of continued rehabilitation depending on return-to-work goals. 1

Positive Prognostic Indicators in Your Case

• Your preserved fine finger pinching ability is a positive prognostic indicator for upper extremity motor recovery. 1

• Your ability to carry 10 pounds demonstrates functional strength preservation, which suggests good potential for further recovery with appropriate rehabilitation. 1