Yudu - sportEX medicine - 1999-2010

Rehabilitation of brachial plexus injury PRACTITIONER PROMPT

Differential diagnosis of nerve root versus brachial plexus lesions Cervical nerve root

Brachial plexus Mechanism of injury

Contributing causes Pain

Parasthaesia Tenderness

Range of movement Muscle power Reflexes

Provocation

Prolapsed disc, stenosis, degenerative disease, osteophytes, trauma

Congenital defect

Sharp, burning dermatome distribution Dermatomal distribution Cervical spine Decreased

Specific myotome affected May be normal

Side flexion, rotation and extension with

Stretch to the cervical spine, depression of shoulder, compression of cervical spine

Congenital canal stenosis

Pain, burning in all dermatomes, +/- trapezius Can be all dermatomes of the arm

Cervical spine and along nerve trunk 1st rib Decreased initially but may return as spasm settles Transient, all myotomes affected May be depressed

Side flexion with compression or stretch may

compression +ve. Neural tissue provocation increase symptoms. Neural tissue provocation test +ve

test will be +ve and is an important part of the sub-acute stage of assessment

The key components in cervical spine rehabilitation are ● Prevent re-occurrence

● Increase flexibility of the cervical spine and surrounding soft tissue ● Increase the functional strength of the stabilising muscles of the respective joints ● Improve proprioception of the cervical spine ● Correct abnormal mechanics ● Teach functional specific exercise relative to the individuals sport ● Provide psychological support

1 Prevention ● Full neuromuscular assessment of the cervical spine and shoulder girdle

● Neurological deficits require appropriate further investigations ie. x-ray, MRI, EMG ● Differentiate between spondylytic changes in cervical spine versus brachial plexus lesion

● Medical team supervising the player is happy that a full rehabilitation programme to cervical spine, thoracic spine and shoulder girdle has been completed ● Analyse any predisposing factors in technique for that particular sport

2 Improve flexibility ● Manual therapy to cervical spine, thoracic spine and upper limb biomechanical chain

● Muscle techniques to maintain range of movement in the scalenii, sternocleido mastoid and trapezius muscles

● Muscle techniques to maintain range of movement in the rotator cuff muscles ● Neural tissue mobilisation techniques to each neural pathway affected. Care must be taken in the acute stage of brachial plexus injury as this will increase pain

3 Increase functional strength ● Local stabilisation of cervical spine before global stabilisation

● Re-educate deep neck flexor muscles – use of pressure biofeedback unit ● Local stabilisation of scapula muscles and shoulder girdle ● Increase isometric and isotonic strength of cervical spine - use of ball, theraband ● Maintain full muscle strength of rotator cuff muscles with functional control of cervical spine

4. Proprioception ● Re-education of the normal feedback

mechanism for local joint control ● Use of ball to assist feedback training

5 Correct abnormal biomechanics

● Ensure normal cervical, thoracic spine and shoulder girdle spine movement

● Physiotherapist discuss with player and coach potential faults in technique which may lead to recurring injury

6 Functional exercises ● Exercises must be specific to the player’s

individual sport

● Exercises must be progressed from non- contact to contact drills

● Exercises must be completed at match- related speeds before return to match situation

● Full, specific fitness test, active and pas- sive before return to match situation

7 Psychological support ● Physiotherapist to liaise with doctor

responsible for player regarding poten- tial psychological problems post injury

● Physiotherapist to discuss with coaches potential problem if player suffers a sig- nificant neck injury

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for special- ist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negli- gence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.