Moderate Left Upper Trunk Brachial Plexopathy (C5-C6): Comprehensive Physiotherapy Management

Case Summary & Diagnosis Correlation

• Comminuted, minimally displaced fractures: scapular spine, superior border, body, lateral border, and glenoid neck
• Minimally displaced fracture of left coracoid process
• C7 transverse process fracture (undisplaced) with soft tissue oedema
• Left 3rd rib buckled fracture; 6th rib hairline fracture
• Minimal left pneumothorax (3-4mm air column); mild haemothorax (<10ml)
• Left upper lobe/lingula air space opacification - lung contusions

• CMAP severely reduced: Lt. Axillary nerve
• CMAP absent: Lt. Musculocutaneous nerve
• CMAP mildly reduced: Lt. Radial nerve
• SNAP normal in all nerves
• Impression: Moderate left upper trunk brachial plexopathy

PHYSIOTHERAPY MANAGEMENT

PHASE 1 - ACUTE PHASE (Week 1 to Week 4)

1. Protection and Positioning

• Shoulder sling (abduction splint/arm sling): A broad-arm sling or a gunslinger orthosis is recommended to prevent glenohumeral subluxation. With deltoid Grade 0/5, the unsupported arm will pull the humeral head inferiorly, causing painful subluxation and stretching the joint capsule.
  • The arm should be positioned in neutral rotation with the elbow at 90°.
  • Avoid the "waiter's tip" (Erb's) posture: adduction, internal rotation, elbow extension, forearm pronation, wrist flexion. This is the classic posture of upper trunk injury and leads to contracture if maintained.
• Bed positioning: Place a pillow under the affected arm when supine to support the shoulder. Avoid sleeping on the affected side.
• Protect the C7 transverse process fracture and rib fractures: No aggressive cervical rotation or deep breathing exercises in early weeks. Caution with neck positioning.

2. Pain and Oedema Management

• TENS (Transcutaneous Electrical Nerve Stimulation): Apply paraspinally at C5-C6 level and over the shoulder for neuropathic/musculoskeletal pain. TENS activates gate control mechanisms and reduces central sensitisation.
• Cryotherapy (ice packs): 15-20 minutes over the shoulder and scapular region, 3-4 times/day in the first 2 weeks to control acute inflammatory oedema.
• Elevation and active finger/wrist movements (these nerves are intact) to prevent dependent oedema in the hand.
• Manual lymphatic drainage (gentle) around the shoulder girdle once acute swelling begins to resolve.
• Intercostal breathing exercises: Critical in this patient given lung contusions and minimal pneumothorax. Teach diaphragmatic breathing and incentive spirometry to prevent atelectasis. Avoid forced expiratory techniques early.

3. Passive Range of Motion (PROM) - Immediate Priority

• Passive flexion (0-180°), abduction (0-180°), external rotation (0-90°), internal rotation
• Perform slowly, 10-15 repetitions, 2-3 times daily
• Special emphasis on external rotation (which is most commonly lost with upper trunk injury due to subscapularis tightening) and shoulder abduction

• Full passive flexion-extension of the elbow
• Supination and pronation (currently weak due to radial nerve involvement)
• Perform in gravity-eliminated positions

• Gentle passive scapular protraction, retraction, elevation, and depression to maintain scapular mobility
• Important given the comminuted scapular fractures - confirm with orthopedic team when mobilization of the scapular region is safe (typically at 4-6 weeks for minimally displaced fractures)

• Active ROM exercises for wrist, fingers, and thumb are important to maintain dexterity, prevent disuse, and support circulation

4. Sensory Awareness

• Sensory stimulation of the lateral deltoid (anesthetic zone): Use different textures (cotton wool, firm brush, cold, vibration) to stimulate the skin in the sensory loss area - begins "priming" cortical representation even before nerve recovery.
• Educate patient to visually monitor the anesthetic zone to prevent inadvertent burns or pressure injuries.

PHASE 2 - SUBACUTE PHASE (Week 4 to Week 12-16)

5. Electrotherapy - Core Component

• Target muscles: Deltoid (axillary nerve), Biceps brachii (musculocutaneous nerve), Supinator (radial nerve branch)
• Rationale: NMES produces passive muscle contractions, preventing denervation atrophy and maintaining muscle fibre viability until reinnervation occurs. It also stimulates Schwann cell proliferation and nerve regeneration.
• Parameters for denervated muscle:
  • Waveform: Faradic-type interrupted DC or exponentially rising current (Galvanic surged)
  • Pulse duration: 100-300 ms (longer pulses needed for denervated muscle as accommodation is lost)
  • Frequency: 1-5 Hz
  • Intensity: Visible contraction without pain
  • Session: 20-30 minutes, daily or 5x/week
• Interferential therapy (IFT): For pain management over the shoulder-neck region. Use 4-pole method with carrier frequency 4000 Hz, beat frequency 80-100 Hz for analgesia.
• Ultrasound (therapeutic): Over peripheral nerve pathway areas (axillary/musculocutaneous nerve course) at 1 MHz, 0.5-1 W/cm², pulsed mode - reported to enhance nerve regeneration by increasing axonal sprouting and Schwann cell migration.
• Low-Level Laser Therapy (LLLT): Applied along the nerve course. Class III-IV laser (830nm or 904nm wavelength) at appropriate energy density has shown evidence for enhancing peripheral nerve regeneration.

6. Assisted Active and Active-Assisted Exercise

• Gravity-eliminated shoulder abduction: Patient lying, arm in pool/hydrotherapy or on powder board. Even minimal deltoid activation should be attempted.
• Gravity-eliminated elbow flexion: Patient in side-lying with forearm on smooth surface (powder board). Encourage maximal effort with verbal and tactile cuing. The Grade 1/5 contraction in biceps indicates the nerve is not completely disrupted - this is the muscle to focus on.
• Proprioceptive neuromuscular facilitation (PNF) techniques: Use diagonal patterns D1 and D2 flexion. The intact hand/wrist can assist in carrying the limb through movement patterns, stimulating cortical motor maps.
  • D2 Flexion pattern (shoulder flexion, abduction, external rotation with elbow flexion) directly targets the C5-C6 myotome
• Overflow/irradiation techniques: Resistance to the unaffected (right) limb can neurologically "overflow" to facilitate weak muscles on the affected side. Bilateral movements are encouraged.

7. Shoulder Girdle Stabilisation

• Strengthen serratus anterior (long thoracic nerve - C5-7, likely partially intact)
• Strengthen trapezius (spinal accessory nerve - not part of brachial plexus, should be intact)
• Scapular retraction exercises against gravity
• Wall push-ups with "plus" (serratus activation)

8. Hydrotherapy

• Buoyancy eliminates gravity, allowing Grade 1-2/5 muscles to move through range
• Warmth promotes tissue extensibility and pain relief
• Resistance is graded by speed of movement and use of floats

PHASE 3 - NERVE RECOVERY PHASE (Month 3 to Month 6+)

• Serial manual muscle testing (monthly)
• Tinel's sign progression down the nerve - advancing Tinel's indicates axon sprouting
• Serial NCS/EMG at 3 and 6 months to track CMAP amplitude changes

9. Progressive Strengthening

• Deltoid: Begin shoulder abduction in gravity-eliminated, progress to against-gravity at Grade 3/5, then resistive exercises with Theraband and free weights
• Biceps: Begin gravity-eliminated elbow flexion, progress to supine curls, then standing curls with progressive loads. Add supination loading (supinator weakness from radial nerve involvement also expected to recover, given mildly reduced CMAP)
• Rotator cuff: External rotation strengthening (infraspinatus/teres minor via suprascapular/axillary nerve) must be prioritized to prevent future impingement

10. Sensory Re-education

• Moving touch discrimination
• Constant touch localisation
• Use of graded textures, temperatures

• Two-point discrimination training
• Object recognition (stereognosis)
• Vibration sense retraining

11. Mirror Therapy

• The patient views the unaffected limb moving in a mirror, creating the visual illusion of the affected limb moving. This stimulates cortical motor areas and reduces central inhibition. Especially useful when the affected arm has no visible movement.
• Particularly beneficial for pain management and maintenance of cortical body map during denervation.

12. Occupational Therapy Integration

• Fabrication of dynamic elbow flexion assist orthosis to support functional elbow use during ADLs
• Overhead sling (counter-balanced suspension sling) attached to a frame - helps patient perform shoulder abduction with gravity eliminated
• Energy conservation training, ADL modifications, return to work assessment

PHASE 4 - FUNCTIONAL RESTORATION (Month 6-12+)

• Task-specific training: reaching, lifting, overhead activities
• Return to work/sport-specific rehabilitation
• Psychosocial support - brachial plexus injury is a life-altering event. Anxiety, depression, and adjustment difficulties are common in young adults. Refer to psychology/counselling as needed.
• Ongoing home exercise programme monitoring
• Re-evaluation for surgical referral if motor recovery stalls (nerve transfer surgery is most effective if performed within 3-6 months of injury; this patient should already be under surgical evaluation given the severity of CMAP changes)

PHYSIOTHERAPY MANAGEMENT SUMMARY TABLE

EVIDENCE-BASED RECENT ADVANCES

1. Neuromuscular Electrical Stimulation (NMES) - 2026 Systematic Review

2. Peripheral Nerve Stimulation for Neuropathic Pain

3. Early Multimodal Rehabilitation - 2026 Case Report

4. Physical Therapy Interventions - Systematic Review (2023)

5. Contralateral C7 Nerve Transfer with Brain-Computer Interface (BCI)

6. Bioengineered Nerve Conduits

7. Three-Dimensional Upper Limb Movement Analysis

8. Robot-Assisted Rehabilitation

KEY PROGNOSIS POINTS FOR THIS PATIENT

• Favorable sign: Normal SNAP (post-ganglionic lesion), complete and pain-free passive ROM, and presence of flicker contraction in biceps (Grade 1/5) - indicates axonotmesis, not complete neurotmesis
• Concerning sign: Absent CMAP in musculocutaneous nerve - this needs urgent 3-month NCS follow-up
• Recovery of elbow flexion is more likely than shoulder abduction. Rockwood and Green's Fractures in Adults 10th ed 2025 states: "40% of C5-C6 injuries recover useful function"
• The radial nerve mild involvement (supinator) has the best prognosis as it is only mildly affected
• Given the patient is 25 years old, active, and this is a moderate post-ganglionic lesion, aggressive early rehabilitation combined with timely surgical liaison gives the best chance of meaningful recovery