Brachial Plexus Injury - PG Level Physiotherapy Management

1. Classification of Brachial Plexus Injuries

By Level

By Seddon/Sunderland Classification

Etiology

• Traumatic: Motorcycle/vehicle accidents (traction/stretch injuries); sporting accidents (football "burner/stinger"), gunshot wounds
• Birth-related (NBPP): Shoulder dystocia, forceps delivery, large birth weight
• Rucksack paralysis: C5/C6 upper trunk from strap pressure
• Iatrogenic: Nerve block complications, surgical positioning
• Neuralgic amyotrophy (Parsonage-Turner): Episodes of severe neuropathic pain followed by patchy paresis, usually upper plexus (C5/C6)
• Tumour/Pancoast: Lower plexus (C8/T1) from apical lung tumour

2. Assessment - The Physiotherapy Framework

Subjective Assessment

• Mechanism and timeline of injury
• Pain character: burning, crushing, electric-shock-like = neuropathic; continuous deafferentation pain in avulsion is notoriously severe
• Functional limitations: ADLs, work, driving
• Psychological status (depression, fear-avoidance)

Objective Assessment

• Shoulder: abduction (C5-axillary n.), ER (C5/6 - suprascapular n.)
• Elbow: flexion (C5/6 - musculocutaneous), extension (C7 - radial)
• Wrist: extension (C6/7), flexion (C7/8)
• Intrinsics: finger abduction, grip (C8/T1 - ulnar)

• Light touch, pin-prick, two-point discrimination by dermatome
• Tinel's sign along the nerve trunk (prognostic for regeneration)

• Horner's syndrome → T1 preganglionic avulsion
• Sweating, skin trophic changes, complex regional pain syndrome (CRPS)

3. Physiotherapy Management - Phase-Based Approach

Phase 1: Acute/Early Phase (0-6 weeks)

• Arm supported in a broad arm sling or collar-and-cuff to prevent glenohumeral subluxation from deltoid/rotator cuff paralysis
• Avoid dependent hanging of the arm - leads to traction on the plexus, subluxation, and oedema
• Pillow support at night; elevation for oedema control
• Cervical pillow/collar for combined root-plexus injuries

• Gentle PROM to all joints of the affected limb daily
• Priority joints: shoulder (prevent impingement/adhesive capsulitis), elbow, wrist, and finger joints (prevent stiffness/contracture)
• Maintain full passive shoulder range especially if deltoid is paralysed (risk of capsular tightening within 2-3 weeks)
• In NBPP: daily PROM is the mainstay of early treatment to maintain muscle length, joint range and reduce glenohumeral dislocation risk (Bailey & Love, 28th Ed.)

• Retrograde massage, compression garments, elevation

• Transcutaneous Electrical Nerve Stimulation (TENS) for neuropathic pain - a standard adjunct in acute neuropathic pain management
• Interferential current (IFC)
• Ice/heat depending on phase and symptom type
• Gentle scar mobilisation once wound healing is complete

• Skin care (loss of protective sensation - inspect daily for pressure areas, burns)
• Positioning instructions
• Realistic prognosis counselling - regeneration at 1 mm/day, proximal muscles recover before distal

Phase 2: Subacute/Regeneration Phase (6 weeks - 6 months, or as function returns)

• Progress from passive → active-assisted ROM (AAROM) → active ROM (AROM) as motor function returns
• Gravity-eliminated positions initially (e.g., shoulder in horizontal plane for shoulder abduction)
• Proprioceptive Neuromuscular Facilitation (PNF) patterns to facilitate movement through diagonal planes

• As reinnervation occurs (earliest return: proximal shoulder muscles before hand intrinsics)
• Open kinetic chain → closed kinetic chain progression
• Theraband, free weights, pool therapy (hydrotherapy reduces gravitational load)
• Biofeedback / EMG biofeedback to facilitate early re-activation of weak muscles

• Applied to denervated muscles to maintain muscle bulk and prevent atrophy while awaiting reinnervation
• Prevents fibrotic changes in muscle during denervation
• Note: True denervated muscle (neurotmesis/avulsion) requires long-pulse duration stimulation (triangular pulses); standard TENS/NMES parameters stimulate intact nerve endings

• Aim: restore neural tissue extensibility and gliding within the nerve bed
• Brachial plexus tension test (BPTT/ULNT) positions used therapeutically in slider vs. tensioner fashion
• Reduces intraneural oedema, adhesions, ectopic neural impulse generation
• Begin gently; can aggravate symptoms if too aggressive

• Early phase: Desensitisation for hypersensitivity/allodynia - graduated tactile stimulation (cotton wool → velcro → rough surfaces)
• Late phase (after protective sensation returns): Discrimination training - textures, shapes, temperature, stereognosis
• Aims to prevent maladaptive cortical reorganisation

• Particularly valuable in complex regional pain syndrome (CRPS) and deafferentation pain
• Sequence: laterality (left-right discrimination), motor imagery, mirror therapy
• Evidence for cortical reorganisation and pain reduction
• Caution: can initially aggravate pain in some patients (Scottish NBPIS physiotherapy protocol)

• Buoyancy supports paralysed limb - enables active movement at MRC grade 2-3
• Warm water promotes circulation and reduces pain
• Excellent for total plexus injuries where gravity-assisted movement is impossible

Phase 3: Chronic/Late Rehabilitation Phase (>6 months)

• Task-specific training: ADL retraining (dressing, grooming, cooking)
• Compensatory strategies for irreversible deficits
• Bimanual tasks; trunk compensation strategies
• Liaison with Occupational Therapy (OT) for splinting, adaptive equipment

• Resting splints: Prevent contractures (wrist and finger drop in lower plexus injury)
• Functional splints: Wrist-extension splints to enable hand function in radial nerve palsy component
• Shoulder supports: Hemi-arm sling, gunslinger orthosis for shoulder subluxation
• Dynamic splints: Lumbrical bar splints, opponens splints for intrinsic muscle loss
• Post-surgical: Specific positional splints after nerve grafts/transfers (per surgeon protocol)

• Progressive resistance training of reinnervated muscles
• Contralateral limb and core training (neuroplasticity - cross-education effect)
• Aerobic fitness

• Closed-chain proprioceptive training (weight-bearing through affected limb when possible)
• Coordination exercises

4. Post-Surgical Physiotherapy

Postoperative Principles

• Immobilisation period: As per surgeon (nerve repairs are protected; typically 3-6 weeks in a specific position)
• Early gentle PROM within allowed range: reduces pain, oedema, adhesion formation
• Muscle re-education: Neural regeneration after nerve transfer takes 3-18 months; biofeedback, mental imagery, and task-specific training facilitate new motor pathways
• After nerve transfer: Patients must learn a "trick movement" - e.g., after Oberlin's transfer, train elbow flexion by mentally initiating wrist flexion (ulnar nerve re-education)
• After tendon transfer: Progressive loading, re-education of the transferred muscle unit
• After free muscle transfer: Strict phased rehabilitation per surgeon protocol

5. Pain Management in BPI - Physiotherapy Role

Physical Modalities

Pharmacological Adjuncts (Multidisciplinary Role)

• First-line: Pregabalin, gabapentin, duloxetine, tricyclic antidepressants (amitriptyline) - strong evidence (Bradley & Daroff)
• Second-line: Capsaicin cream, lidocaine patches, tramadol
• Third-line: Strong opioids, botulinum toxin A
• Surgical pain management: Dorsal root entry zone (DREZ) lesioning for intractable deafferentation pain

6. Special Situations

Obstetric / Neonatal Brachial Plexus Palsy (NBPP)

• Upper plexus (Erb's C5/C6): Waiter's tip posture (arm adducted, internally rotated, elbow extended, forearm pronated, wrist flexed). Good prognosis if biceps function present early.
• Lower plexus (Klumpke's C8/T1): Hand involvement; Horner's = poor prognosis
• Early PT: Passive ROM daily by parents (parent education critical), prevent glenohumeral dislocation and contracture
• Surgery indicated if elbow flexion not recovered by 3 months; later orthopaedic reconstruction for muscle imbalance
• (Schwartz's Principles of Surgery, 11th Ed.)

Thoracic Outlet Syndrome (Neurogenic TOS)

• Lower trunk (C8/T1) pattern
• Conservative PT: Scalene/pectoralis minor stretching, cervical muscle strengthening, posture correction, thoracic mobility, neural mobilisation
• "Brachial plexus involvement with minimal signs and symptoms often responds to conservative treatment with physiotherapy and shoulder girdle exercises." - Rosen's Emergency Medicine

Pancoast Tumour / Radiation Plexopathy

• Palliative rehabilitation goals; pain management (TENS, positioning, graded activity)
• Lymphoedema management after radiotherapy/surgery

7. Psychological and Psychosocial Management

• Explain pain neurophysiology (pain education)
• Screen for depression and anxiety (refer to psychology/psychiatry)
• Set realistic, patient-centred goals
• Address fear-avoidance and kinesiophobia
• Link to peer support groups (e.g., TBPI Group, UBPN)
• Facilitate return to driving, work, social participation (liaison with OT/social work)

8. Outcome Measures (PG Level Knowledge)

9. Physiotherapy Prognosis Principles

• Neuropraxia: Full recovery expected; weeks to months
• Axonotmesis (incomplete): Recovery follows at 1 mm/day from injury site; proximal muscles recover before distal
• Upper trunk lesions have better prognosis than lower trunk (Bradley & Daroff)
• Muscle must be reinnervated within approximately 1 year or irreversible fibrotic changes occur - this is the critical window for intervention
• Recovery of elbow flexors/extensors and shoulder girdle after grafting is relatively good; forearm and hand intrinsics have poor recovery
• Delays >6 months in surgical repair reduce outcomes significantly
• Functional recovery in 83% satisfaction rate after BPI surgery (Kim et al., large series of 1000+ patients)

• Bradley and Daroff's Neurology in Clinical Practice - Early Management, Long-Term Management, Neuropathic Pain (p. 2611-2612)
• Bailey & Love's Short Practice of Surgery, 28th Ed. - Brachial Plexopathy (p. 655)
• Schwartz's Principles of Surgery, 11th Ed. - Birth Injuries
• Campbell's Operative Orthopaedics 15th Ed. 2026 - BRACHIAL PLEXUS
• Rosen's Emergency Medicine - Management, Thoracic Outlet Syndrome
• Scottish National Brachial Plexus Injury Service (SNBPIS) - Physiotherapy Protocols
• Medscape: Traumatic Brachial Plexopathy Treatment & Management