Disorders of the brachial plexus lead to loss of function of the fingers and thumb, wrist, arm or shoulder. This dysfunction can be due to weakness, sensory changes, or pain of the affected limb. Pain can be a result of the nerve injury itself or from complications such as joint contracture which can result in painful tightening of the muscles and connective tissue resulting from lack of movement. Overuse injuries such as shoulder or wrist pain of the unaffected arm or new neck or back pain can result from compensation for the weakness of the affected limb. The constellation of these symptoms may limit your return to work or necessary activities of daily life. Your multidisciplinary clinic visit will most likely include recommendations for physical and/or occupational therapy. Therapy sessions are typically 2-3 days per week for an hour and include stretches and exercises that the patient must do independently.
Home Rehabilitation Program
A home rehabilitation program is critical to the success of these interventions as the vast majority of time is spent outside of the clinician’s office. Therapies are often limited in duration lasting for weeks to several months. Nerve recovery is a very slow process that can take months and years to complete regardless of the need for surgical intervention for treatment after a brachial plexus injury. After clearance from your physician or health professional, a regular home routine will allow for the greatest chance of functional improvement. The primary goals of this program focus on improving function of the affected limb through avoidance of complications resulting from the nerve disorder via targeted strengthening, and accommodating for lack of function using braces or special equipment. A home program often means completing stretches or strengthening exercises several times per day. It empowers you, the patient, to direct and participate in recovery and is dependent on effective communication between you and your multidisciplinary team. Through prompt, coordinated communication, barriers to patient participation (i.e. poor brace fitting leading to non-use) can be corrected prior to follow-up appointments to maximize the time for recovery.
Joint Range of Motion and Muscle Stretching
Stretching and range of motion of the upper limb joints at the direction of a therapist or physician can help to avoid significant contracture. Joint contracture limits the ability to harness muscle strength that results from nerve recovery. Typically after a brachial plexus injury, the shoulder joint can become contracted in a turned in (internal rotation) position with the arm positioned close in to the body (shoulder adduction). The forearm can become significantly limited in the ability to turn the palm face up (supination) or face down (pronation). Weakness in the fingers and hand can lead to the fingers being in a flexed position. Stretching often is most effective when done several times per day or in conjunction with heat or ice to help relax muscles and connective tissue and limit pain.
Bracing to Help Protect Joints or Provide Functional Support
Weakness of the shoulder muscles can lead to the unsupported weight of the arm slowly pulling down on the shoulder causing partial dislocation (subluxation). Proper support of the arm during daily activities and at bedtime can lead to less pain. A custom or off-the-shelf brace called an orthosis may be prescribed for your use to avoid contracture of the fingers, thumb, wrist or elbow. Some orthoses are to be used specifically at night time to keep the limb in a certain position or they can be used during the day to help complete activities.
Targeted Muscle Strengthening & Other Treatments
Home strengthening exercises focused on the shoulder and upper limb can often include resistance bands and may be done laying on the back (supine), belly (prone) to eliminate gravity and better support the affected limb as muscle strength improves. Based on the discretion of your therapist your home program may also include electrical stimulation (e-stim) that can be performed at home after basic instructions. Mitts or other constraints can be used on the unaffected limb to promote the use of the affected one (constraint therapy). In addition to strengthening weak muscles, mirrors can be used to reflect movements of the unaffected limb onto the affected one, tricking the eye and brain into seeing normal function on the affected side (mirror therapy).
Pain can be a significant complication that can limit use of the affected limb despite the use of medications or other treatments. At home, patients can use desensitization techniques including baths of contrasting temperature water, stroking or touching of the arm with different textures to reduce pain. Transcutaneous electrical stimulation (TENS) unit can lead to pain relief. Topical medications or creams. Adherence to a medication plan developed in partnership with your healthcare provider can result in improved pain relief.
Adaptive Equipment and Devices to Help Improve Function
Finally, adaptive equipment such as large handle silverware, pens, razor or other devices may be recommended and provided for your use at home or in the community to help improve function.