EFFECTIVENESS OF STRUCTURED MOTOR RETRAINING PROGRAM IN ADULTS WITH TRAUMATIC BRACHIAL PLEXUS INJURY UNDERGONE NERVE TRANSFER: A CASE REPORT

S. Subin¹, T. Jimshad², K. Sreejith³, K. Pradeep⁴

Background: Nerve transfers and functioning free muscle transplantation become the only possible and reliable restorative options for the avulsed brachial plexus injuries. There is limited evidence assessing the efficacy of physiotherapy after multiple motor nerve transfer in pan brachial plexus injury of avulsed type.

Purpose: Purpose of this case report to illustrate the techniques used to improve sensory and motor recovery of a subject who had undergone multiple nerve transfer with pan brachial plexus injury.

Methods: A prospective, single case study was used to follow a 22 year-old male who had right pan brachial plexus injury two and half years ago. Informed consent was taken from the patient. Patient has undergone multiple nerve transfer in Elite Hospital, Thrissur; spinal accessory nerve to suprascapular nerve, phrenic nerve to posterior division of lower trunk & contralateral C7 spinal nerve to lower trunk and musculocutaneous nerve. Study was undertaken in Department of Physical Medicine and Rehabilitation, Government medical college, Kottayam, Kerala. After surgery, Patient reported to physical medicine department and was examined by the Physiatrist.  On his initial visit he had a muscle power of zero for entire muscles in the right upper limb except scapular muscles. Patient reported to physiotherapy section on every alternate day. Subject was trained with donor activated focussed rehabilitation approach. Subject was also taught with induction exercises, neuromuscular electrical stimulation and passive range of motion as a home exercise programme.

Results: After 6 months, his shoulder flexion / abduction was 60 degree with M3 power. Subject was able to initiate triceps by 12 months and biceps by 18 months post-surgery.  At present his shoulder active range of motion improved to 170 degree of flexion and 160 degree of abduction with M4 power.   Active range of motion of elbow was full with M4 power for biceps and triceps. Now he can perform wrist flexion and finger flexion with a grade of 3.  Till present, he was treated for 2 years & seven months, 3 days per week, one hour per day. Routine follow up at regular intervals was done by Physiatrist to assess re-innervation through needle EMG.  

Conclusion(s): Even though same C7 spinal nerve was transferred to elbow, wrist and finger flexors, a unique action of donor muscle action was required to recruit the recipient elbow, wrist and finger flexors seperately. Thus structured motor retraining program establishes new motor patterns for recipient muscles, fosters cortical reorganisation and promotes earlier recovery than expected. This motor training program is based on current recommendations and the authors’ experience with incorporating it in a clinical setting.

Implications: A systematic combination of all these techniques delivered to the patient not only would deliver successful rehabilitation outcomes on post nerve transfers at an earlier than expected but also help improve patient’s quality of life. This recommendation also enhances the intercommunication between Surgeons, Physiatrists and Physiotherapists in improving patients’ recovery at an earlier than expected duration.

Funding, acknowledgements: Not applicable as this was a case report.

Keywords: Donor activated focussed rehabilitation approach, lnduction exercise, Physiotherapy after nerve transfer

Topic: Musculoskeletal: upper limb

Did this work require ethics approval? No

Institution: Government Medical College, Kottayam, India

Committee: N/A

Reason: As it was a case study, informed consent was taken from the patient