Brachial plexus injury is one of the difficult medical problems in the world. After several decades of efforts, innovative techniques have brought new hope for the patients, especially in the surgery types of the nerve repair. In 1970, GU Yu-dong1 firstly proposed phrenic nerve transfer and in the early 1980s, he created and developed contralateral C7 transfer and multi-nerve transfer. However, many patients did not have comprehensive rehabilitation after operation, so they could not expect good functional recovery. Now we put forward the comprehensive rehabilitation after operation and observed the therapeutic effects of comprehensive rehabilitation in treating dysfunctions after brachial plexus injury. The basic principle of rehabilitation on peripheral nerve injury is to maintain and recover the function of joints and unaffected muscles, prevent or eliminate disuse-atrophy, and promote nerve regeneration and functional recovery.2
Forty-three patients with brachial plexus injury were selected from the Hand Rehabilitation Section of the Department of Hand Surgery of Huashan Hospital, Fudan University between 2005 and 2011 (seven females and 36 males, age range 19-57 years). The patients were randomly divided into two groups: the treatment group, which totaled 21 patients (including 14 cases of total brachial plexus injury and seven cases of branch brachial plexus injury), who were treated with comprehensive rehabilitation with four (30-day) courses in the hand rehabilitation department and the control group, which totaled 22 patients (including 16 cases of total brachial plexus injury and six cases of branch brachial plexus injury), who did not go through a comprehensive rehabilitation therapy. The gender, age, nature of injury, and education of the two groups had no significant differences (P >0.05). All patients underwent operation and they accepted rehabilitation 4 weeks post-operatively (Table 1).
The patients were all diagnosed with brachial plexus injury clinically and operated on with the conventional microsurgical treatment such as neurolysis and multi-nerve transfer (phrenic nerve transfer, contralateral C7 transfer, inter-costal nerve transfer, etc.).
Treatment group was treated with comprehensive rehabilitation therapy as follows. The control group rehabilitated themselves with home-based electrical nerve stimulation and occupational therapy; that is, they did not go through a comprehensive rehabilitation therapy.
Promoting nerve regeneration
We used transcutaneous electrical nerve stimulation, TENS21 (made by Homer Medical Apparatus, Co., Ltd., Japan). Spinal cord type was prescribed. One positive electrode was placed at C5-T1, one negative electrode was placed at the supraclavicular fossa and another negative electrode was placed at a certain position according to the surgery type (Table 2). We adjusted the intensity depending on the degree of patient tolerance and the therapeutic time was 30 minutes, twice a day.
Preventing muscular atrophy
We used mid-frequency therapeutic apparatus, BA2008-IV type (made by Ben’ao New Technology, Co., Ltd., Beijing, China). Prescription and period of time were made and two electrodes were placed at certain positions (muscle) according to the type of surgery (Table 2). We adjusted the intensity according to the degree of patient tolerance and the therapeutic time was 20 minutes, twice a day.
According to the patients’ surgery type and the degree of muscular atrophy, appropriate occupational therapy and functional training methods were selected for them. The training methods were totally different for different types of nerve transfer (Table 3). The principle was that the patient was taught to complete the auxiliary motions which the donor nerve originally controls, imagine simultaneously and complete the expected motion passively which the recipient nerve controls. The patient was also taught to do all sorts of functional exercises of brachial plexus injury.3 Therapeutic time of all the above training was 45 minutes, twice a day.
Pressing, rolling, kneading, pinching, and vibrating manipulation were mainly used on the upper limb to restore and maintain passive motions on stiff joints. Therapeutic time was 20 minutes, twice a week.
Each cycle of comprehensive rehabilitation was of 30 days duration, which was defined as one course and patients went through four courses in all. There was a suspension of 1 week between each course for physical therapy and no suspension for tuina and occupational therapy.
The patients of the control group rehabilitated themselves at home for various reasons and they were treated with home-in electrical nerve stimulator (NMS, low-frequency electrical stimulator, made by the Institute of Hand Surgery Department in the Huashan Hospital, Shanghai, China). We determined the location where the electrodes were to be put according to their different surgery types and taught them how to do functional exercises at home. Physical therapeutic time was 30 minutes and occupational therapeutic time was 45 minutes, both twice a day.
Therapeutic effects evaluation
All joint motions were evaluated according to the proposal of the Upper Extremity Functional Evaluation (Tables 4–8) put forward by the seminars in the Hand Surgery Academy, Chinese Medical Association in March, 2000. Patients of both groups were assessed by brachial plexus function evaluation after four courses.
Electromyogram (EMG) examination
EMG was performed during the surgery and at the end of the completion of the four courses.
All data were analyzed statistically by the SPSS13.0 software (SPSS Inc. Chicago, IL, USA). Paired sample t test was used to analyze the differences between before and after treatment results in the same group and to compare the differences among the groups. The data are shown as mean±standard deviation and the test of significance level was set at P=0.05.
Brachial plexus function
In the treatment group, there were significant differences in the scores of brachial plexus function pre- and post-treatment (P <0.01) in both total and branch injuries (Table 9).
While in the control group, there were no statistical differences in the scores of brachial plexus function pre and post-treatment (P >0.05). The scores of the two total injury groups had statistical differences (P <0.01), while the scores of the two branch injury groups had statistical differences (P <0.05) after four courses.
For patients with total brachial plexus injury, who had underwent multi-nerve transfer, the appearance of “regeneration potential” of the treatment group by dominative muscles of recipient nerve was earlier than that of the control group, and had statistical differences, P <0.05 (Table 10).
Thus, it concluded that comprehensive rehabilitation was more effective in treating dysfunction after brachial plexus injury than nonstandard rehabilitation.
Brachial plexus injury was regarded as an international medical problem. The rehabilitation department of Hand Surgery Department at Huashan Hospital, Fudan University, carried out the comprehensive rehabilitation treatment from 2004. During the past 7 years, constant exploring and combining of the previous experiences in treating brachial plexus injury with rehabilitation treatment, doctors thought that the neurotization before and after surgeries was good for preventing muscular atrophy. Strengthening myodynamia, the body training, and passive motion can enhance the function recovery rate of brachial plexus injury. The rehabilitative mechanism of nerve recovery should be paid more attention. Research has proved that the function recovery after brachial plexus injury depends on the functional recomposition metabolism of nervous system. The recomposition after surgery observed around injury area can reflect the flexibility of the self nervous system. During this process, according to the therapeutists’ comprehensive direction and the patients’ earnest cooperation, combining patients’ thought and functional motion, focusing the brain on patients hand function, and forming the comprehensive rehabilitation, we will find that the function recovery will be better and the patients will be more confident after some time. Especially to the characteristics of brachial plexus injury such as nerve injury, muscular atrophy, joint stiffness, adhesion, and pain; the patients will not get the expected effect after some years without the comprehensive rehabilitation treatment both at home and in some local hospitals, although the surgeries are successful.
Now we use comprehensive rehabilitation treatment to the brachial plexus injury both before and after the surgeries as follows (Figure 1): (1) Nerve and muscle electrical facilitation techniques:4 we used transcutaneous electrical nerve stimulation to stimulate the injured paralyzed muscles with spinal cord mode. The stimulation can excite the denervated muscles, speed up the regeneration of nerves, and make the function of nerves better by activating the central nervous system. The animal experiment of a university in Tokyo proved that the low-frequency electric power continues the stimulation to the spinal cord and rebuilds the function of injured nerve through the brain spinal cord and cerebral cortex. As we all know, the structure and function of the mature brain are flexible, the adjustment of the injured nervous system intervenes the recovery and rebuilds the injured nervous function through outer means such as TENS-21, mid-frequency, massages and occupational therapy, to help the motor center to stimulate the injured palsy muscle and recover the peripheral nerve injury. (2) Mid-frequency therapy:5 we use the advanced domestic multi-functional mid-frequency electro-therapeutic apparatus to treat patients. This therapy has no electrolyte effect to the human tissues. Mid-frequency electricity changes between the positive and negative electrodes, having no acid-base reaction in the electrode and by avoiding the chemical stimulation to the skin. Mid-frequency electricity obviously lowers the skin resistance to lead strong electricity to the deep human tissues. Multi-functional mid-frequency electro-therapeutic apparatus can improve the local blood circulation, smoothen and increase the blood flow, promote the absorption of inflammatory material, and reduce tissue edema. Otherwise, the apparatus can also soften scars and release adhesion. The mid-frequency stimulation can increase the distance between cells and tissues, such that it can separate the adhesion of connective tissue fiber, muscle fiber, and nerve fiber. After several surgeries, the patients with brachial plexus injury easily develop symptoms such as tissue adhesion, scar contracture, and muscle pain; hence, mid-frequency therapy has good effect on the recovery of such diseases. Except for the above effects, the therapy is also used to stimulate the contraction of the normal muscle and the denervated muscle, improve the nutrition of the muscle and tissue, and prevent muscular atrophy. The long-term treatment of mid-frequency therapy can prevent the muscular atrophy and increase the muscle strength. (3) Hand functional occupational therapy:6 the hand rehabilitation department will instruct every patient and design a training program that will help the functional recovery and makes the patients get the courage to overcome the illness. The occupational therapy focuses on the various muscles and joints including shoulder, elbow, wrist, palm, and fingers to do passive motion, then positive motion, and then gradually resistant motion, till the recovery of the function.7 (4) Tuina therapy:8 Physical manipulation is applied to the human body and it performs the effects through physiological reaction, nervous reflexion, and body fluid regulation. Tuina therapy can increase and improve blood circulation and restore the impaired tissue. When the manipulation is exerted on human body to a certain degree, continuous pressing and rolling will increase the blood flow and lymphatic return, and relieve the edema and contraction. Besides, it can also enlarge the excitation of the peripheral tissue and increase the conductibility through peripheral susceptors and afferent nerves. Moreover, continuous manipulation on human body will bring about heat energy that can nourish the muscle and improve the skin elasticity, and then slow down the muscular atrophy due to denervation.
The above-mentioned comprehensive rehabilitation, especially combining physiotherapy and occupational therapy with Tuina massage, has a good effect on the brachial plexus injury before and after the surgery and helps the patients’ shoulder, elbow, and wrist recover quickly. But we have not find an effective way to the functional recovery of intrinsic muscles. Our research shows that comprehensive rehabilitation is sure to promote the nerve regeneration, prevent muscular atrophy, and extend the range of every joint including shoulder, elbow, wrist, palm, and fingers.
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5. Zhou J, Xu W, Zhang L. Rehabilitation of the upper nerve injury (Self Training and Family Care), first ed. Shanghai: Fudan University Press; 2008: 13-16.
6. Zhou J, Xu W, Zhang L. Rehabilitation of the upper nerve injury (Self Training and Family Care), first ed. Shanghai: Fudan University Press; 2008: 23-21.
7. Gu Y, Wang S, Shi D. Hand surgery, first ed. Shanghai: Shanghai Science and Technology Publishing House; 2002: 249.
8. Liang BZ, Zhou J. Practical orthopaedic acupuncture and massage. Hongkong: Institute of Chinese Medicine, The Chinese University of Hong Kong; 2003: 33-35.