The goal of physical therapy in treating patients with brachial plexus injuries is to maximize functional recovery, increase physical strength, reduce compensatory substitutions, and restore form and developmental growth. The first step in obtaining this goal is to provide support and family education. Parents are naturally distraught about their child’s injury and during the perinatal period have no information about a brachial plexus injury or the recovery. It is therefore paramount to provide as much education as possible. The therapist should help families develop home exercise programs in addition to positioning recommendations, joint protection, and splint use and applications. Help families develop positive language toward the affected arm instead of negative terms. In addition, it is also important to utilize the unaffected arm as a model for all type of therapy and exercises the parents should perform on the affected arm. Equally important is teaching the family on how to handle and hold the child.
Following education, an assessment needs to be made whether the patient will require joint protection and positioning. It is important during therapy that the affected arm is positioned in the line of sight to increase awareness. Positioning should also be done to maintain the appropriate alignment of the glenohumeral joint, elbow, wrist and hand. Orthotics may be necessary to help position flaccid wrists and hands.
Sensory education is also done during therapy to increase visual, tactile and auditory stimulation. This will improve awareness and impulse to use and include the affected arm. All stimulation is done to and from the affected side. Feeding, approaching, crib set-up, and interaction are all from the affected side. Multi-sensory toys are useful in assisting with sensory reeducation.
The mainstay of therapy will focus on increasing range of motion. The passive range of motion exercises should include all planes of the shoulder, elbow, wrist and fingers. Ideally, 10-15 repetitions 2-3 times per day should be done. Each motion should be done slowly and held for 3-5 seconds. Focus should be on shoulder abduction and external rotation, elbow flexion and forearm supination. Passive range of motion will maximize muscle elasticity, limit contractures and provide sensory input of normal movement patterns.
Active range of motion exercises are implemented through activities that promote bilateral movements and strengthening. It is also important to facilitate normalized movement patterns and limit compensatory substitutions to prevent inadvertently strengthening bad patterns and maladaptive postures. Again focus is on shoulder abduction and external rotation, elbow flexion and forearm supination and hand flexions and extension. Promoting the use of bilateral activities and utilizing aggressive therapy will promote normalized postural control and muscle balance.
Once a patient has established a good foundation with PROM and AROM exercises as a foundation to proper motion and stretching, strengthening is then added to the physical therapy regimen to increase function. Therapists and family should focus on strengthening proximal to distal starting with scapular stability, glenohumeral joint strengthening, elbow flexion, forearm supination, wrist extension and flexion and finally finger flexion and extension. Activities for strengthening will have to be adjusted for age and developmental goals as children grow. However, activities such as reaching, jumping/climbing, throwing, bouncing, catching, carrying, protective responses, and support reflexes should all be utilized. Fine motor coordination such as pinch grasp, opposition, writing, cutting, and drawing also assist in the therapy of each patient.
Additional factors to take into consideration while formulating therapy plans are to encourage consistent daily routines and participation in activities especially when they are difficult. It is also important to reward a child when they attempt or initiate use of the affected extremity. Therapist and families are encouraged to incorporate therapy into daily activities so they are not viewed as “therapy”. Focus should be on using the affected extremity and on the child’s abilities not on their inabilities. It is also important to break automatic “poor” habits and to reinforce “quality” movements through repetition of normalized patterns. And, the most important factor is to make the activities fun. Play activity ideas such as those listed to the right have worked well in out therapy regimens.