Our program currently has two registered occupational therapists that evaluate brachial plexus and peripheral nerve patients who attend our clinic. They directly contribute to the provision of interdisciplinary clinic evaluations, recommendations, and therapy services.
For those patients who are followed in our clinic but who receive therapy from their local communities, our therapists are able to consult with distant health providers about continued care and treatment strategies to maximize progress. Contact Information: [email protected] or 734-936-5017
The principal goals of therapy are to:
- Maintain integrity of the joints during the recovery process.
- To achieve maximal muscle use at a tolerable pain level as the nerve is recovering.
- Educate in safety and protection due to sensory loss.
- Maintain strength in unaffected muscles.
- Assist in returning to productive activities
Interventions might include:
- Range of motion exercises and stretching
- Joint compression and weight bearing to facilitate muscle contraction
- Bilateral motor planning activities
- Facilitating optimal alignment in the shoulder and scapula to promote smooth movement in all directions
- Aquatic therapy when indicated
Acute Stage-Early Injury or Pre-surgery
In patients with motor nerve injury, initial therapy involves patient education and protection of the joints, including the ligaments and tendons from further stress. Therapy is started in the early stages after a nerve injury to maintain passive range of motion in the affected joints and to maintain muscle strength in the unaffected muscles. Slings, splints or both may be needed for support. If used, patients are taught to maintain good passive range of motion to minimize potential of contractures. If the shoulder has been affected, involving the C5-6 nerves, continued downward stress at the glenohumeral joint can result in a subluxation due to loss of the support in the rotator cuff muscles. A sling is helpful to support the joint. The California Tri-Pull Taping Method (Hayner, Kate, Effectiveness of the California Tri-Pull Taping Method for Shoulder Subluxation Poststroke: A Single-Subject ABA Design, American Journal of Occupational Therapy, November/December 2012, Vol. 66, 727-736. doi:10.5014/ajot.2012.004663), though utilized on post-stroke patients to treat inferior subluxation, has been effective in providing some, but not total support and reduce pain for some patients with C5-6 nerve involvement. Use of electrical stimulation in nerve recovery remains controversial. There are no known studies supporting that electrical stimulation can prevent nerve degeneration or enhance regeneration. What is most concerning is the risk of thermal burn underneath the electrodes especially if there is significant sensory loss. If the patient demonstrates activation of a muscle, electrical stimulation we will consider after 3 months following an injury but with caution. Each of our patients is assessed with much prudence. We rarely use it in the early stage following the injury. Homes programs are essential. Routinely have the patient demonstrate the exercise to make sure they are doing it safely and correctly.
Pain can be a prominent factor following a nerve injury and throughout the entire course of recovery. Challenges with sensation, paresthesia and persistent pain may require treatment and are usually followed by a primary care physician or pain specialist. Therapy can offer various therapeutic modalities such as; TENS, moist heat pack, sensory desensitization techniques or ultrasound.
Patients are usually immobilized for 6 weeks following surgery. Once therapy has been prescribed the initial treatment consists of gentle range of motion of the joints and soft tissue which have been immobilized. Splints and supports are used as needed. Patients are instructed in exercises to maintain strength in the unaffected muscles. As recovery progresses sensory and motor reeducation are applied to maximize movement and function. The rate of spontaneous recovery is difficult to predict due to the wide range of severity of the brachial plexus injuries. Prognosis is assessed for each patient individually based on the type and degree of involvement of each lesion. The regeneration process can take up to a year to 5 years and therapists are cautioned not to be aggressive in treatment approaches especially in the beginning stages of recovery. Significant stress put on a paralyzed muscle through stretching and strengthening can delay and may even affect nerve recovery. When progressive strength return is observed which is usually in the late state of nerve regeneration, more intense treatment can be applied. As a general rule, if there is measurable return of muscle strength due to muscle regeneration and minimal pain exhibited associated with the nerve injury, therapists can move forward with treatment challenges. Every patient’s recovery is so different with no predictable patterns to be able to state clear guidelines for progression. A severely injured nerve may require months before initiating resistive exercise to the involved muscle. This includes weight bearing positions. If the scapula stabilizer muscles are not strong enough, too much load and stress are placed into the joint and surrounding tissue. Sufficient nerve healing time has to happen first. On the other hand, a less severe injured nerve may be able to tolerate light resistance within the first month. If the movement is very difficult, with obvious compensatory motion, and there is increased pain, tingling, and numbness during or after the exercise, it is most likely too soon to be attempting the exercise. Nerve mobility during recovery should be gently approached. Focus on the unaffected muscles and surrounding stabilizers. Nerves often take considerable time to regenerate and both patient and therapist must be gentle, tolerant and patient in the process. During the recovery process, therapy sessions may at times be more frequent, and other times spaced out with patient being seen for more monitoring and updating of the home exercise program. One of the most challenging areas throughout the rehabilitation process is minimizing contractures. When a joint has to be supported, some postures are obviously not ideal but necessary in order for patients to carry on with daily tasks. Therapists cannot emphasize enough to the patient how key it is to maintain the passive range throughout this time and follow through with home exercises. Patients who seem to experience the best results are ones who are consistent and persistent in their follow through. Routinely have the patient demonstrate their home exercises for you to make sure they are doing them correctly.
If a patient is not able to return to their previous employment or will need assistance to prepare for, obtain or retain, encourage them to contact vocational rehabilitation services in their respective regions. http://www.in.gov/fssa/ddrs/2636.htm