What is the recommended rehabilitation protocol for severe wrist drop, including dynamic splinting, gentle exercises, functional electrical stimulation (FES) and transcutaneous electrical nerve stimulation (TENS)?

Rehabilitation Protocol for Severe Wrist Drop

For severe wrist drop, use functional electrical stimulation (FES) combined with intensive task-specific wrist extension exercises—NOT TENS alone, and avoid static splinting which prevents recovery. 1, 2

Primary Treatment: Functional Electrical Stimulation (FES)

FES is specifically recommended for patients with wrist motor impairment and impaired muscle contraction. 1, 2

Device Application

• Apply FES with surface electrodes to the wrist and forearm extensor muscles to directly stimulate muscle contraction 2
• Initiate FES within the first 6 months post-injury for optimal outcomes, as this represents the critical window for motor recovery 2, 3
• Use FES as a time-limited intervention during the first several weeks, typically for 30 minutes, 3 times daily during active attempts at wrist extension 1, 3

Expected Outcomes with FES

• Improved muscle force in wrist extension is the primary measurable outcome supported by meta-analysis of RCTs 2, 4, 5
• Short-term increases in motor strength and motor control with reduction in impairment severity 1, 2
• Critical limitation: Evidence demonstrates improved muscle force but does NOT consistently show improvements in functional outcomes or activities of daily living 2, 4

Active Rehabilitation Protocol (Essential Component)

Do NOT use FES as standalone treatment—it must be combined with active motor practice. 2, 4

Task-Specific Wrist Extension Practice

• Begin with supported wrist extension movements on a table surface 2, 3
• Progress to unsupported movements as control improves 2, 3
• Practice functional activities that progressively challenge wrist extension in multiple positions and contexts 3
• Perform repetitive, goal-oriented activities that challenge wrist extension with graded difficulty 3

Structured Resistance Training

• Start with very low-intensity resistance at 40% of 1-repetition maximum with 10-15 repetitions 2, 3
• Progress to moderate intensity (41-60% of 1-RM) with 8-10 repetitions as tolerated 2, 3
• Perform resistance training 2-3 times per week to allow adequate recovery between sessions 3
• Do NOT progress resistance too quickly—start with very low intensity during initial sessions to avoid muscle damage 3

TENS: Limited Role in Wrist Drop

TENS is NOT recommended as a primary treatment for severe wrist drop rehabilitation. 6, 7

• TENS may provide adjunctive analgesic effects when used simultaneously with exercise at high frequency and intensity at sensory threshold 6
• Evidence for TENS in motor recovery is conflicting and primarily addresses pain management, not motor function restoration 6, 7
• The 2025 VA/DoD guidelines suggest offering FES, neuromuscular electrical stimulation, or TENS as adjunctive treatment, but FES has the strongest evidence for motor function improvement 1

Critical Contraindications

Avoid Static Splinting

Avoid static splinting or immobilization of the wrist, as this prevents restoration of normal movement and promotes learned non-use. 1, 2

Potential problems with splinting include:

• Increasing attention and focus to the area, thereby exacerbating symptoms 1
• Increasing accessory muscle use and compensatory movement strategies 1
• Immobilization leading to muscle deconditioning 1
• Learned non-use 1
• Increased pain 1

When Splinting Might Be Considered

• Try strategies that encourage normal movement patterns and resting postures before considering splinting 1
• If a removable splint is issued, monitor regularly and empower the patient to discontinue use in the event of adverse effects such as pain and skin breakdown 1

Recovery Timeline

• Most motor recovery gains occur within the first 6 months, making this the critical window for intensive rehabilitation 3, 4
• Rapid symptom relief typically occurs within 3-4 months with appropriate FES and structured rehabilitation 3
• Continue rehabilitation for 9-12 months for optimal functional recovery, even after wrist extension returns 3
• Maintenance of gains over 12 months is possible with appropriate intervention 3

Common Pitfalls to Avoid

• Do not rely on passive modalities alone—active motor practice is essential 2, 4
• Do not use constraint-induced movement therapy for severe wrist drop—this requires minimum motor criteria of 20-degree wrist extension and 10 degrees for each finger, which severe wrist drop patients do not meet 1
• Do not delay FES initiation—early application within 6 months shows stronger evidence of efficacy 2, 3, 4
• Do not expect functional improvements from FES alone—muscle force improvements do not automatically translate to functional gains without task-specific practice 2, 4