When patients experience traumatic injury to the nerves in the brachial plexus or other peripheral nerves that serve the hand, arm or shoulder, they often lose function and sensation in some or all of the affected limb. Whether or not surgery is required, commitment to a long-term physical therapy program is a key step toward recovery and can make the crucial difference in long-term ability to function.
As members of the multidisciplinary team that provides care at the Center for Brachial Plexus and Traumatic Nerve Injury at Hospital for Special Surgery (HSS), it is beneficial if physical and occupational therapists get involved as soon as the patient is diagnosed, explains Alexandra MacKenzie, OTR/L, CHT, with the Hand Therapy Center at HSS. "At that point our role is to assess the patient's strength and range of motion. We begin a regimen of exercises adapted to the specific injury as soon as the patient has medical clearance."
For some patients, those with neurapraxia (a nerve that has been stretched, but not disrupted or severed) for example, the course of treatment involves several months of monitoring by the Center for Brachial Plexus and Traumatic Nerve Injury team to see if the nerve will recover on its own. During this period, physical therapy helps the patient to maintain the injured limb's range of motion and prevents unaffected muscles from atrophying. Movement is also important to help treat edema or swelling in the area, which can contribute to stiffness.
Sometimes a patient will wear a splint as part of his or her post-injury recovery. For example, if the patient is unable to use the muscles that control the wrist, the joint flexes forward in an abnormal position. Splinting helps hold the wrist in a neutral position during recovery—thereby protecting it and preventing possible contractures from developing that may limit movement.
Those who undergo a surgical procedure, such as a nerve graft or a nerve transfer to repair their injury, may start gentle exercises the first day after their surgery. "In the beginning, the exercises may be passive," explains Ms. MacKenzie. "If the patient can't move the limb, the therapist or, eventually, a trained family member or caregiver, does it for them."
Retraining the brain to send information along grafted nerve tissue or along a new nerve pathway is the long-term and ultimate physical therapy goal for these patients. For example, a patient who has undergone a procedure in which the nerve that once served the muscles surrounding the ribcage has been rerouted to deliver electrical information to the bicep must be retrained to contract the bicep. In this case, deep breathing may be the initial exercise used to help activate the new connection.
Another technique involves the use of mirrors. The patient's injured arm is placed behind a mirror while he or she watches the reflection of the unaffected arm in the mirror move. This is a way of "tricking" the brain into thinking the injured arm is moving, and helping to restore connection to that limb. "It's very exciting to see the connection and therefore movement come back," Ms. MacKenzie adds. Crunches, abdominal exercises and cardiac activity can all play a role in recovery as well.
Because nerve regenerates very slowly, patients may not see results for six months or even a year after surgery. Progress often continues several years following surgery. "We help patients understand that it's important to keep moving to maintain joint flexibility, even if they're not seeing immediate results. Otherwise, even if the nerve is eventually able to reactivate the muscle, if the joint is stiff, function will still be impaired," says Ms. MacKenzie.
Biofeedback is sometimes used to help patients stay motivated and assess their progress. To use the mechanism, an electrode is attached to the skin over the affected muscle. As the muscle contracts, the electrode transmits information to the machine that registers the strength of the contraction. This information is then communicated back to the patient through lights on a bar and with a sound emitted by the machine. As the muscle contractions grow stronger, the lighted bar becomes longer and the beeping sound becomes louder. "This is a great exercise to use early on in the patient's therapy. Even if they can't gauge how much they're contracting the muscle, and even if they're not seeing movement in the muscle, the machine lets them know that it's happening. It's just one more tool we can use to help create that pathway between brain and muscle," says Ms. MacKenzie
During recovery, therapists also assist with adaptive techniques for one-handed dressing, bathing and other daily activities. If the patient is unable to use the hand he or she writes with, therapeutic techniques can also train the other hand to perform this function.
Because patients come from all over the country to seek care at the Center for Brachial Plexus and Traumatic Nerve Injury, the therapists at the Center have experience in helping patients find programs close to home, once their initial treatment is completed.
"We spend a lot of time with patients helping them establish realistic goals and expectations and encouraging them to remain motivated. Because we see them over and over again, we have the opportunity to keep discussing their progress," says Ms. MacKenzie. "In the beginning these injuries can be so overwhelming; it can be hard to absorb all the information about recovery at once."