Received: 23 September 2020 Accepted: 26 January 2021

DOI: 10.1002/pmrj.12566

NARRATIVE REVIEW

Physical therapeutic treatment for traumatic brachial

plexus injury in adults: A scoping review

Alessandra Carolina de Santana Chagas MSc1 | Débora Wanderley PhD1 |

Josepha Karinne de Oliveira Ferro MSc1 | Alexa Alves de Moraes PT1 |
Fernando Henrique Morais de Souza MD2 | Angélica da Silva Teno! rio PhD1 |
! jo de Oliveira PhD1
Daniella Arau

Abstract
1
Department of Physiotherapy, Federal
University of Pernambuco, Pernambuco,
Brazil
Traumatic brachial plexus injury (BPI) is one of the most disabling injuries of the
2
Peripheral nerve neurosurgery outpatient
upper extremity, often requiring specialized treatment and a prolonged rehabilita-
~o, Pernambuco,
clinic, Hospital da Restauraça tion period. This scoping review was carried out to identify and describe the
Brazil physical therapy modalities applied in the rehabilitation of adult individuals with
BPI. Electronic databases, gray literature, and reference lists were searched,
Correspondence
!jo de Oliveira, Department of
and studies meeting the following eligibility criteria were included: (a) interven-
Daniella Arau
Physical Therapy, Federal University of tions including any physical therapy modality; (b) individuals age ≥18 years old;
Pernambuco, Av. Jorn. Aníbal Fernandes, and (c) a clinical diagnosis of BPI. The literature search yielded 681 articles of
!ria, Recife,
173 - Cidade Universita
which 49 met the inclusion criteria and had their outcomes, treatment parame-
Pernambuco 50740-560, Brazil.
Email: sabinodaniellaufpe@gmail.com ters, and the differences between conservative and pre- and postoperative treat-
ment phases analyzed. The most commonly used physical therapy interventions
Funding information were in the subfields of kinesiotherapy (ie, involving range of motion exercises,
Coordenaça~o de Aperfeiçoamento de Pessoal
muscle stretching, and strengthening), electrothermal and phototherapy, manual
de Nível Superior, Grant/Award Number: 001
therapy, and sensory re-education strategies. Although several physical therapy
modalities were identified for the treatment of BPI in this scoping review, the
combination of low levels of evidence and the identified gaps regarding the treat-
ment parameters challenge the reproducibility of such treatments in clinical prac-
tice. Therefore, future controlled clinical trials with clearer treatment protocols for
individuals with BPI are needed.

INTRODUCTION deficits in upper limb movements as well as impaired

Traumatic brachial plexus injury (BPI) is a severe neu-
ral condition resulting from trauma, and is one of the
most disabling injuries of the upper limb.1-3 The most
frequent cause of BPI is motorcycle accidents usually
involving young men.1-4 Although there is a paucity of
epidemiological data, a recent systematic review indi-
cates an estimated frequency of 0.17 to 1.75 cases per
100 000 inhabitants/year in countries such as the
United Kingdom, Japan, Switzerland, Brazil, the Czech
Republic, and Slovakia.1
The functional consequences of the injury are
related to several factors, such as the degree of the
nerve injury, the location of the injury, the mechanism
underlying the trauma, and individual specific factors.2,5
Common symptoms observed after a BPI may include
muscle strength and sensitivity.2,6,7 In addition, BPI
may limit the patient’s ability to perform work-related
and daily life activities, thus potentially affecting their
emotional and psychological health and quality of life,
and exerting a significant socioeconomic impact.6,7
Rehabilitation plays a fundamental role in the recov-
ery after trauma, and generally early intervention is
warranted to minimize secondary complications.7-9
Recent advances in microsurgical techniques have
offered a better prognosis regarding the functional motor
recovery of patients with BPI when compared to tradi-
tional techniques such as nerve repair/grafting.2,10,11 On
the other hand, there has not been significant advance-
ment in physical therapy treatment for BPI7 and the
treatment modalities that best suit this population are yet
to be elucidated.

PM&R. 2021;1–31. http://www.pmrjournal.org © 2021 American Academy of Physical Medicine and Rehabilitation 1
2 PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY
Given the emerging nature of scientific evidence
investigating physical therapy modalities for BPI, a
scoping review was selected and deemed as an appro-
priate method to provide a broad overview of this topic
and to identify gaps in the literature. Different from sys-
tematic reviews, which focus on specific questions
about the effectiveness of a certain treatment or prac-
tice, scoping reviews map and identify the types of
available evidence in a given field while providing an
overview of the key aspects and gaps related to that
topic.12,13 Therefore, the purpose of this scoping review
was to identify and describe the various physical ther-
apy modalities used as rehabilitation strategies for adult
individuals with BPI.
METHODS
This scoping review was conducted in accordance with
the methodology for scoping reviews,13 and an a priori
protocol was developed and published.14 This review
addressed the following research questions: (a) What
physical therapy modalities are applied for rehabilitating
adults who experienced BPI? (b) What were the main
outcomes assessed? (c) What physical therapy modali-
ties are implemented in the surgical and conservative
treatment approaches? (d) What frequency, duration,
and intensity were adopted for such modalities?
Search strategy
A three-step search strategy was conducted to identify
published and unpublished studies and reviews. The
first step comprised a preliminary search in MEDLINE
and Web of Science databases to find relevant articles
and to develop a full search strategy. In the second
step, the search strategy, including all identified key-
words and index terms, was adapted for each database
and a second search was undertaken in November
2018 and updated in June 2020 (Figure 1). The follow-
ing databases were searched: MEDLINE, Scopus,
Cumulative Index to Nursing and Allied Health Litera-
ture (CINAHL), Web of Science, The Cochrane Library
and Physiotherapy Evidence Database (PEDro) via
CAPES journals Portal, and LILACS via BVS Portal
databases. Finally, the third step consisted of an addi-
tional search of nonindexed journals, gray literature,
and reference lists of all identified reports and articles.
Sources of unpublished studies and gray literature
searched included the Brazilian Digital Library of The-
ses and Dissertations (BDTD), the CAPES Thesis and
Dissertation Catalog webpages, as well as Google
Scholar search tool, which had the first pages of the
search results ranked by relevance considered. In addi-
tion, the reference lists of the included articles were
assessed.
Inclusion criteria
Types of sources
This scoping review considered several study designs
for inclusion, such as different types of reviews, clinical
trials, case reports, theses, and dissertations as well as
gray literature. No publication year or language restric-
tions were applied.
Participants
Adult individuals 18 years of age or older, with a clinical
diagnosis of trauma-induced BPI (including all levels
and types of lesion) were considered.
Concept
This review considered studies that explored physical
therapy techniques or modalities that were clearly
defined, including those used by physical therapists to
encourage, maintain, or restore an individual’s physical
and physiological well-being. Examples include thera-
peutic exercises, electrical stimulation, hydrotherapy,
musculoskeletal manipulations, and patient education.
Studies that implemented only surgical treatments, or
failed to specify the physical therapy techniques applied,
or addressed obstetric brachial plexus paralysis and/or
non-traumatic BPI were excluded.
Context
This review included studies developed in any health
care center with physical therapy service available for
patients with BPI, with no restrictions based on specific
geographical, cultural, or social contexts.
Study selection and data extraction
After the initial search, all identified records were col-
lated, uploaded into Microsoft Excel 2010 software, and
duplicates were removed. Titles and abstracts were
screened against the inclusion criteria by two indepen-
dent reviewers and any disagreements that arose
between the reviewers were resolved through discus-
sion. Data were extracted and organized in a table
developed by the reviewers on Microsoft Word 2010
according to the proposed scoping review protocol. The
extracted data included (when reported): (a) authors and
year of publication; (b) study location—country and
place of research conduction (context); (c) study design;
(d) population—number of participants included, sex,
and age; (e) level and time of injury; (f) surgery—in the
de SANTANA CHAGAS ET AL. 3

Search strategy
Search date: 22. June 2020
Database Search strategy

MEDLINE #1 (Brachial plexus neuropathies) AND adult AND (neurological

(PubMed) rehabilitation). #2 (Brachial plexus neuropathies) AND adult AND
(exercise therapy). #3 (Brachial plexus neuropathies) AND adult
AND (Physical and Rehabilitation medicine). #4 (Brachial plexus
neuropathies) AND adult AND (Physical therapy modalities). #5
(Brachial plexus injury) AND adult AND (Neurological
rehabilitation). #6 (Brachial plexus injury) AND adult AND (exercise
therapy). #7 (Brachial plexus injury) AND adult AND (Physical and
Rehabilitation medicine). #8 (Brachial plexus injury) AND adult
AND (Physical therapy modalities).

Scopus #1 “Brachial plexus injury” AND adult AND “Neurological

rehabilitation”. #2 “Brachial plexus injury” AND adult AND
“exercise therapy”. #3 “Brachial plexus injury” AND adult AND
“Physical and Rehabilitation medicine”. #4 “Brachial plexus injury”
AND adult AND “Physical therapy modalities”

Web of Science #1 Brachial plexus neuropathies* AND adult AND Neurological

rehabilitation*. #2 Brachial plexus neuropathies* AND adult AND
exercise therapy*. #3 Brachial plexus neuropathies* AND adult AND
Physical and Rehabilitation medicine*. #4 Brachial plexus
neuropathies* AND adult AND Physical therapy modalities*. #5
Brachial plexus injury* AND adult AND Neurological
rehabilitation*. #6 Brachial plexus injury AND adult AND exercise
therapy*. #7 Brachial plexus injury* AND adult AND Physical and
Rehabilitation medicine*. #8 Brachial plexus injury* AND adult
AND Physical therapy modalities*.

CINAHL #1 Brachial plexus injury AND Neurological rehabilitation AND

adult. #2 Brachial plexus injury rehabilitation AND adult. #3 Brachial
plexus injury AND adult AND exercise or physical activity. #4

FIGURE 1 Search strategy with timeframe and search terms for each type of sources

event it was performed and type of surgery;
(g) outcomes—primary and secondary outcomes and
the assessment tool for each outcome;
(h) interventions—physical therapy modalities and
parameters, total number of sessions, and frequency,
duration, and intensity of each one.
RESULTS
Nine hundred twenty-three studies were identified in
the initial database search. After duplicates were
removed, 658 articles had their title and abstract
screened, of which 71 were considered for full-text
screening, resulting in 26 eligible studies for this review.
Additional searches in non-indexed journals, gray litera-
ture, andreference lists identified 23 articles; thus a
total of 49 studies were included in this review
(Figure 2).
The majority of the studies included were case
reports/series and non-systematic reviews published
over the last 10 years (Table 1). Three articles derived
from the same research group and consisted of one
case series15 and two articles that refer to the findings
4 PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY

Brachial plexus injury AND adult AND physical therapy or

physiotherapy or rehabilitation. #5 Brachial plexus injury AND adult
AND modalities in physical therapy.

Cochrane #1 Brachial plexus neuropathies AND Neurological rehabilitation

AND adult

LILACS #1 (neuropatias do plexo braquial) AND (reabilitação neurológica)

AND (adulto) #2 (neuropatias do plexo braquial) AND (adulto) AND
(terapia por exercício) #3 (neuropatias do plexo braquial) AND
(adulto) AND (modalidades de fisioterapia)

PEDro #1 Brachial plexus injury

Aditional Sources: search terms

Google Scholar: “Brachial plexus injury” rehabilitation

Brazilian Digital Library of Theses and Dissertations (BDTD): Brachial plexus injury

CAPES Thesis and Dissertation Catalog: Brachial plexus injury; plexo braquial.

FIGURE 1 (Continued)

from this case series.16,17 To avoid redundancy on
reporting these results, our appraisal focused mainly on
the two articles that offered a more in-depth description
of the protocol utilized.16,17
Patient characteristics
The studies were carried out in 15 countries and
included 593 individuals, with 83% of them male, who
experienced BPI (Table 2). The average age of patients
could not be established due to some studies reporting
only the minimum and maximum ages of the sample
and others reporting only the average age. Thus some
studies were included even though the minimum18-20 or
maximum age16,21-23 of the patients was either lower or
higher than the eligibility criteria of this review, since
the sample was composed mainly of patients who met
the criteria (the estimated pooled mean age reported in
these studies was 25.2 to 50.2 years). Three studies
included individuals with varied types of peripheral
nerve injury and reported a sample ratio of 52 of 107
(48.6%),24 2 of 10 (20%),22 and 32 of 50 (64%)25 of
patients with BPI in their total sample. In another
study,26 7 of 19 (37%) of the sample were individuals
with BPI, whereas the other participants were patients
who underwent amputation.
Most studies reported the affected nerve
trunks,9,16-22,27-38 of 356 reports (ie, combined total
sample); 280/356 were classified as lesions in the three
trunks and 76/356 as upper trunk injuries. One study23
classified the BPI as total paralysis (n = 37 patients)
and incomplete paralysis (n = 43 patients). Two case
reports39,40 classified the BPI according to the affected
region (ie, infra- or supra-clavicular sites), and other
authors16-18,29-31,36,41 detailed the injuries by including
more than a single classification category, such as root
avulsion injury and degree of peripheral nerve injury.
Eight studies24,25,42-47 either did not mention or did not
make clear their criteria for injury classification
(Table 1).
Six studies22,24,26,42-44 did not mention whether sur-
gical procedures had been carried out or not, whereas
the other studies that considered patients who had
undergone any form of reconstructive surgery provided
details regarding type of surgery, such as neurotization,
neurolysis, and grafts16,20,23,25,29,31,33,34,40; nerve trans-
fers16-20,23,27,29,31-36; and muscle transfers.17,23,27,45 In
nine studies,9,21,28,30,37,41,46-48 patients only underwent
physical therapy.
Main pre- and post-intervention outcomes
Muscle strength was the most frequently assessed out-
come (66.7%),9,16,19,20,22-24,27-30,32,34,36-38,40,41,43-45,47
followed by superficial and/or deep sensitivity
(42.4%),9,20,22,24,27,28,37,38,40,41,43,45-48 range of motion
(ROM),23,27-29,32,34,38,40,43,46-48 and pain9,18,20,21,26,31,33,
39,40,42,44,46
(36.4%). Limb function was assessed in six
studies17,18,32-34,41 and quality of life33,42,43,46 in four.
Other parameters assessed were deep tendon
reflexes,9,28,40,46,47 handgrip strength,34,45 limb girth,32,43
postural analysis,40 anthropometric measurements,
de SANTANA CHAGAS ET AL.
F I G U R E 2 PRISMA flowchart of study selection and inclusion process.
Source: Moher D, Libera_ A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-
Analyses: The PRISMA Statement. PLoS Med 6 (6): e1000097
respiratory aspects and the occurrence of trigger
points,40 activities of daily living (ADLs) performance,45
anxiety levels,42 phantom limb pain and movements,26
and patient satisfaction and preference regarding the
rehabilitation setting.21
Several instruments were used to assess the reported
outcomes. For evaluating muscle strength, the Muscle
Manual Testing and the Medical Research Coun-
cil9,16,19,22-24,29,30,32,34,36,37,44,45 were reported in some
studies, whereas the modified Kendall test and Oxford
scale were used in others.38,41,47 Pain intensity was mea-
sured through the Visual Analogue Scale
(VAS)20,21,31,33,42,44,46,48 and the Numeric Rating Scale
(NRS).18,40 Other instruments to assess pain were the
Brief Pain Inventory and the Wong Baker scale,20 McGill
Pain Questionnaire (MPQ),42 and its short version SV-
MPQ.26 The Disabilities of Arm, Shoulder and Hand
questionnaire (DASH),18,32,33,41 the Action Research Arm
5
test (ARAT),17,33 and Southampton Hand Assessment
Procedure (SHAP)33 were used to assess upper limb
function. Quality of life was measured through the
36-Item Short Form Health Survey (SF-36)33,42,43 and the
World Health Organization Quality of Life (WHOQoL-
BREF) questionnaires.46 Range of motion was reported
in degrees in all studies, although only a few stud-
ies28,32,34,38,43 described the use of a goniometer for mea-
surement. Only 5 of the 14 studies that evaluated
sensitivity described the instruments used: the SORRI
monofilaments or aesthesiometer,20,48 the Louisiana
State University Medical Center System (LSUMC),22 and
diverse materials41,43 such as pins, needles, test tube,
and hammer.
Table 3 shows the recommendations described in
the review articles regarding physical therapy modalities,
objectives, and rehabilitation circumstance (ie, conser-
vative treatment, pre- or postsurgery).
6 PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY

TABLE 1 Characteristics of the included studies demonstrated frequencies from once to twice a
Characteristics of the included studies (n = 49) n (%) week,9,46,47 three to five times a week,37,47,48 and daily
sessions.37,41 Each session ranged from 4548 to
Type of study
50 minutes9,46 in duration.
Intervention 4 (8) The physical therapy modalities included
Case report 21 (43) kinesiotherapy (eg, muscle strengthening,28,30,37,41
Retrospective review 5 (10) using elastic bands,30 range of motion (ROM)
Review 14 (29) exercises,9,28,30,37,41 stretching exercises,9,38,41 and
Cross-sectional 1 (2) home-based exercises,38,41,47,48), use of sling,30,41 elec-
Gray literature 4 (8)
trical and phototherapy (eg., supervised home-based
electrostimulation protocols,37,41 biofeedback,37 laser
Year of publication
therapy,48 transcutaneous electrical nerve stimulation
1980–1989 2 (4)
[TENS]9), peripheral magnetic stimulation,44 hydrother-
1990–1999 2 (4) apy,41,46 acupuncture,30; manual therapy,30,41 (including
2000–2009 14 (29) neural mobilization,47,48 proprioceptive neuromuscular
2010–2020 31 (63) facilitation (PNF) techniques,9,47) and functional task
Type of BPI classification used training.9,47
Total or partial (trunks, roots) 22
Infra- or supraclavicular 3
Physical therapy in surgical cases
Pre/ postganglionar/avulsion 11
(pre- and postoperative management)
Degree of peripheral injury 2
Did not make clear or provide 8 Two studies21,24 used identical physical therapy proto-
any classification
cols for both conservative and surgical treatment
Total of participants 593 approaches. Only 523,25,27,29,45 of the 18 studies involv-
Sex ing patients who underwent surgical treatment
Male 492 (83) described their preoperative physical therapy interven-
Female 47 (8) tions. In addition, five review articles8,49-52 also
Not stated 54 (2 studies) described the physical therapy modalities used most
Surgical management
commonly during the preoperative phase for individuals
with BPI. The main physical therapy modalities adopted
Yes 443 (75)
for the pre- and postoperative rehabilitation phase in
Not, only conservative 30 (5)
surgical cases and their respective goals are described
Not mentioned 117 (20) in Table 4. Four studies32-34,36 investigated the use of
Abbreviation: BPI, brachial plexus injury. robotic technologies as a rehabilitative strategy for sur-
gical cases and are appraised in greater detail under
the “Physical Therapy and Technology” subsection
Physical therapy as a conservative later in this article.
treatment (nonsurgical approach) In addition to the therapeutic interventions mentioned
before (Table 4), other physical therapy modalities were
The present review identified nine studies9,21,28,30,37,41,46- less frequently used postoperatively such as TENS,31
48
(eight case reports) that addressed conservative treat- the Cordata method,38 the PNF concept,40 laser ther-
ment only. Of these studies, two involved athletes who apy22,48 and mirror therapy.16,51 A literature review53
experienced BPI; two were rare cases of postmassage addressed Traditional Chinese Medicine (TCM) inter-
session injury; one case of a fall from scaffold; one case ventions, such as acupuncture, fumigation therapy, mox-
of both upper and lower limb polytrauma, one patient ibustion, and massage therapy, as postoperative
injured by a firearm projectile, and one patient with bilat- rehabilitative strategies to treat pain after BPI surgery.
eral BPI after mechanical restraint. None of these individ- Furthermore, two studies23,37 used occupational
uals experienced total plexus injury. In addition, the and physical therapy interventions combined with a pri-
lesions were predominantly limited to C5 and/or C6 nerve mary focus on sensory re-education and adaptation of
roots alone, with one of these patients46 presenting with ADLs. Finally, two studies investigated the use of differ-
accessory nerve involvement. Moreover, only three stud- ent therapeutic methods (ie, virtual reality plus mirror
ies detailed the nerve injury as axonotmesis28 and therapy26 and transcranial magnetic stimulation or
neuropraxia.30,41 transcranial direct current stimulation42) for the treat-
The treatment period ranged from 5 weeks ment of painful conditions (ie, phantom limb pain with
(in cases of neuropraxia) to over 28 months. In terms of root avulsion26 and neuropathic pain42) in individuals
weekly frequency of treatment, home-based protocols with BPI. However, it was not possible to clearly
TABLE 2 Characteristics of the clinical and retrospective studies (n = 30)
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

Monsivais 2020 United States – The Case series study - Total (with C5 rupture and Contralateral C7 nerve - Sensitivity (Semmes- Modalities (starts after
Hand and retrospective review avulsion from C6 - T1 transfers (all). Weinstein 3 weeks
Microsurgery n = 11 (10 men, 1 woman) roots). monofilament postoperative):
Center of El Age: 5-47 years Uninformed. testing); - Kinesiotherapy (passive
Paso, El Paso, - Muscular strength ROM; resistive
de SANTANA CHAGAS ET AL.

Texas. (BRC Muscle exercise programs);

Testing Grading - Hydrotherapy (exercises
System); antigravity when
- Pain (Brief Pain contractions starts);
Inventory, VAS, - Electrostimulation (after
and Wong Baker 4 weeks; including
scale). daily home program);
- Dynamic splinting.
Duration: unclear.
Rich et al 2019 United Kingdom - Case Study Neuropraxia, injury to the left Unrealized. - Muscular strength Modalities:
Royal London n = 1 (man) brachial (Oxford grading - Sling;
Hospital, Barts Age: 28 years plexus (lateral and posterior scale); - Kinesiotherapy (active-
Health NHS Trust, cord). - Sensitivity (test with assisted ROM,
London. Two months. pins and needles); strengthening
- Sulcus sign; exercises and self-
- Upper limb function management
(DASH). stretching exercises in
home program);
- Manual therapy (muscle
energy technique and
gentle joint
distraction);
- Electrostimulation
(NMES, including
home stimulator;
starting at 30 Hz);
- Hydrotherapy.
Frequency: daily (NMES).
Duration: 6 months.
Hruby et al 2019 Austria - Medical Uninformed. Total/severe brachial plexus Elective amputation (all) - Upper limb function sEMG biofeedback
Sturma et al 2018 University of n = 6 (men) including roots avulsions. and selective nerve and (ARAT) (structured
Vienna Age: 27–55 years Uninformed. muscle transfers. rehabilitation protocol
including sEMG-
guided signal training
in three phases, with a
table top prosthesis,
hybrid prosthetic hand
and prosthetic
training).
(Continues)
7
 8
TABLE 2 (Continued)
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

Duration: 22 ± 4.32
sessions (30 min).
Sturma et al 2019 Austria - Medical Uninformed. Superior trunk and/or C7 (3) Several nerve transfers. - Muscular strength Modalities:
Sturma et al 2018 University of n = 5 (3 men, 2 women) C7-T1 (1) (MRC - 0/5) Phase 1 - without active
Vienna Age = 22-68 years Total (1) muscle contraction:
Uninformed. - Patient education
(explanations about
the injury, surgery and
rehabilitation);
- Home exercise program
(exercises previously
performed within a
therapy session);
- lateralization training
(left/right
discrimination -
5-10 min; twice a day);
- mirror therapy (5-10 min;
twice a day);
- kinesiotherapy (active
ROM exercises;
exercises for body
symmetry, trunk
stability, and posture);
- splints or orthoses;
Phase 2 (When detected
the first volitional
contraction of the re-
innervated muscle):
- sEMG biofeedback
(training motor
activation, home
program 10-20 min/
day);
Phase 3 (with sufficient
muscle strength):
- Motor re-learning
strategies (home
program sEMG;
strengthening
exercises; activities of
daily living)
Duration: 23 ± 4.20
sessions (30 min).
(Continues)
PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY
TABLE 2 (Continued)
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

Oliveira et al 2019 Brazil – Case Study. Bilateral BPI, selective and Unrealized. - ROM (uninformed); Modalities:
Deolindo Couto n = 1 (man) generalized bilateral - Sensibility tactile, - PNF (motor irradiation
Neurological Age = 32 years. denervation of the arm, vibratory and technique, isotonic
Institute, Federal forearm and hand muscles. arthrokinetic combination, diagonal
de SANTANA CHAGAS ET AL.

University of Rio 4 months. (uninformed); upper limb patterns,

de Janeiro.
Assis and Andrade Brazil - Federal Pilot, Crossover, Placebo-
2019 University of controlled, Clinical Trial
Paraiba. (Master’s thesis)
n = 20 (men)
Group 1 (active stimulation)
n = 12
Age = 33,53 ± 9,9 years.
Group 2 (simulated
stimulation), n = 8
Age = 30,62 ± 6, 80 years.
- Tone and reflexes using elastic and
(uninformed); manual resistance);
- Balance - Kinesiotherapy and
(uninformed); home exercise
- Muscular strength program (active-
(Kendall scale - assisted ROM,
0/5). isometric and self-
assisted exercises;
self-mobilization
exercises; active-
assisted exercises
against gravity);
- Neural mobilizations
(median, ulnar and
radial nerves);
- Functional task training;
Duration: 28 months.
Frequency: 3 to 1
session/ week
Unclear. Uninformed. - Pain (VAS; MPQ); Modalities:
(percentage of motor and - Anxiety (State-Trait - rTMS (“Magnetic
sensory involvement by Anxiety Inventory - Stimulator Neuro-MS/
dermatomes was IDATE); D" - Neurosoft Ltd.
reported). - Quality of life (SF-36); target area M1; 10 HZ,
Group - Adverse effects 100% intensity; 25
1:34,01 ± 31,04 months; (questionnaire). series; 27 sec of
Group duration with 17 sec of
2:44,44 ± 36,96 months. interval; 5 sessions
and 12 500 pulses);
- tDCS (“TCT-Research®”
- Trans Cranial
Technologies Ltd.
Anodic electrode was
positioned at
contralateral M1 and
cathodic electrode
was positioned at
contralateral supra
orbital area; 5
(Continues)
9
TABLE 2 (Continued)

10
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

sessions in 5
consecutive days;
20 min/session; 2 mA;
0,057 mA/cm2).
Duration: 10 sessions (5
consecutive sessions/
each stimulation
period; 20 min/
session; interval of
30 days).
Osumi et al 2018 Japan - University of Uninformed. All cases of avulsion injury Uninformed. - Phantom limb pain Virtual Rehabilitation with
Tokyo Hospital n = 7 (men) (complete =3). intensity (SF-MPQ) Mirror Visual
Age: 39-58 years 8-38 years - Phantom limb Feedback (single session
movements involving three tasks).
(bimanual circle- Duration: 20 min.
line coordination
task - BCT)
^
Milicin and Si rbu Romania - Comparative Study Uninformed. Uninformed. Clinical: Modalities:
2018 Emergency County n = 52 - Muscular strenght - Ultrasound on the
Hospital in Age: 35-65 years (MMT - 0/5); affected nerve (direct-
Timisoara. - Superficial and coupled; I = 0,5 W/
profound sensitivity cm2; d = 5 min);
(uninformed). -Thermotherapy in the
Electrophysiological: areas innervated by
- Accommodation the affected nervous
coefficient α roots (T = 40-42! C;
(Siemens Universal d = 15 min/session);
- Neuroton 286); - Electrostimulation of the
- Motor nerve muscles that were
conduction velocity partially or totally
(Keypoint - ENM / denervated (d = 8 min/
EP SySTEM). sessa~ o);
- Kinetotherapy (1to 2
sessions/day);
- Manual stimulatory
massage (d = 15 min).
3 complex treatment
cures:
Duration: 14 days/cure;
Interval: 3 months/cure.
Humlen 2018 Czech Republic - Case study Infraclavicular lesion. Reinnervation of the - Posture and Modalities:
Oblastní Nemocnice (bachelor thesis) Nine months. axillary nerve and breathing pattern - Electrostimulation to the
Kladno in n = 1 (man) musculocutaneous (visual wrist extensors and
Prague. Age: 18 years nerve with grafts and examination); flexors (monopolar
PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY

(Continues)
TABLE 2 (Continued)
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

surgical exploration of - Anthropometrical technique; single

the suprascapular, data (cm); pulse stimulation of
median, ulnar and - Movements of the 30-40 mA; 10-20 c/m;
radial nerve. spine and pelvis; d = 10 min);
de SANTANA CHAGAS ET AL.

- Passive and active - Kinesiotherapy (passive

ROM, muscle ROM and active-
length and strength resistive exercises);
(Kendall-2005); - Soft tissue treatment:
- Palpation and trigger scar, skin and fascia
point identification; (Lewit);
- Basic neurological - Scapular mobilization
examination (Ko !lar- (Lewit);
2013): sensibility, - Relaxation of
pain (NRS - 0/10) hypertoned muscles
and deep tendon (Lewit);
reflex. - Kenny method;
- PNF on the affected arm
(“reversal of
antagonists” and
“hold-relax”
techniques)
Duration: 12 sessions
Kubota et al 2018 Japan - Case report Unclear. Modified Steindler-Leo - Muscular strength Preoperative:
Department of n = 2 (men) P1- uninformed; Mayer procedure to (MMT - 0/5); - Kinesiotherapy (ROM
Rehabilitation Age: P1-20 years e P2- P2-1 year and 5 months of restore elbow flexion. - Grip strength exercises and
Medicine, Keiyu 57 years. lesion. (uninformed); strengthening of the
Orthopedic - Sensory examination remaining muscles,
Hospital, (uninformed); wrist flexion and
Tatebayashi, - Assessment of ADL extension);
Gunma. performance - Electrostimulation (low-
(uninformed); frequency) for the
- Active ROM denervated muscles
(uninformed). (uninformed);
Postoperative:
- Immobilization;
- Kinesiotherapy (active
ROM exercises for
elbow flexion and wrist
extension, manual
resistance exercise,
strengthening of wrist
extension with manual
resistance and using a
weight).
(Continues)
11
TABLE 2 (Continued)

12
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

Duration: 10 and
12 months
postoperatively.
Kitisomprayoonkul Thailand - Case report Incomplete right lesion at the Unrealized. - Muscular strength Modalities:
2018 Department of n = 1 (woman) upper trunk level with (MMT - 0/5); - Kinesiotherapy (ROM
Rehabilitation Age: 35 years axonal loss. - Sensibility and strengthening
Medicine, Uninformed. (uninformed). exercises);
Faculty of - Electrostimulation
Medicine, (uninformed);
Chulalongkorn - Biofeedback
University, (uninformed);
Bangkok. Frequency: once daily:
5 days/week (physical
therapy), 7 days/week
(home-used
electrostimulation);
Duration: 6 months.
Oliveira et al 2016 Brazil - Case report All cases with complex lesion Two underwent surgery. Clinical: Modalities:
Pontifícia n = 3 (2 men, 1 woman) involving the three trunks. - Active ROM - Electrostimulation on
Universidade Age: 25,35 and 40 years Uninformed. (goniometry); elbow and wrist
Cato !lica do Rio - Muscular strength extensors and external
Grande do Sul (Oxford modified shoulder rotators
(PUCRS). Porto from Kendall); (Intellect Combo 48 -
Alegre, Rio - Superficial and deep Chattanooga, EUA;
Grande do Sul. sensibility triangular waveform;
(uninformed); phase term:
Electrophysiological: 70-100 ms; phase
- Changes in ENM. interval: 800-1000 ms;
d = 20 min/dia);
- Chordata Method
(d = 90 min/session)
Frequency: 2,5; 5 e 4
sessions/week in each
case respectively.
Duration: 1 year; 1 year
and 4 months; 2 years
and 5 months in each
case respectively.
Chang et al 2015 Taiwan - Case report Predominantly involving the Unrealized. Clinical: Modalities:
Department of n = 1 (woman) upper trunk. - Muscular strength - Kinesiotherapy (Passive
Physical Age: 58 years Uninformed. (uninformed); ROM exercises,
Medicine and - Sensibility strengthening and
Rehabilitation, (uninformed); stretching exercises);
- Home exercise program.
PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY

(Continues)
TABLE 2 (Continued)
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

Tri-Service - Deep tendon reflex Duration: 12 weeks.

General Hospital (uninformed);
- Passive and active
ROM (goniometry);
de SANTANA CHAGAS ET AL.

- Pain (VAS);
Electrophysiological:
- Changes in ENM.
Limthongthang Thailand – Prospective, single-group, Total C5-T1 (33); Unrealized (21); Realized - Pain (VAS); Electrostimulation of the
et al 2014 Department of nonrandomized clinical Upper C5-C6/C7 (7) (19) - Skin maximal biceps brachii muscle:
Orthopedic study Uninformed. temperature at the (Model Siriraj ES1;
Surgery, Faculty n = 40 (33 men, 7 women) electrodes area monophasic triangular
of Medicine Age:18-73 years. (thermal infrared wave form, pulse
Siriraj Hospital, imaging camera); width: 80 ms; pulse
Mahidol - Patient satisfaction interval: 1 s, and
University, (score 0-10) and electrical intensity: 0-
Bangkok treatment location 100 mA; d = 15 min).
preference Duration: one session.
(questionnaire);
Batista and Arau
! jo Brazil - Case report Predominantly involving the Transfer to wrist, hand and - Muscular strength Preoperative:
2013 Rede Sarah de n = 1 (man). upper trunk, mainly C6 root finger extension - (uninformed); - Kinesiotherapy
Hospitais de Age: 34 year. and posterior cord. modified Burkhalter - Active ROM (maintenance of ROM
Reabilitaça~o, Uninformed. technique. Trapezius (uninformed). and strengthening
Brasília, Distrito muscle transfer - muscles to be
Federal. modified Saha transferred);
technique. Postoperative (radial
palsy):
- Immobilization (plaster
and sling);
- Shoulder mobilization;
- Scar massage;
- Desensitization (with
textures);
- Whirlpool;
- Kinesiotherapy (passive
exercises, transferred
muscle training,
manual activities, light
counter-resistance
exercises).
Postoperative (transfer for
shoulder):
- Immobilization (plaster
and sling);
(Continues)
13
TABLE 2 (Continued)

14
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

- Kinesiotherapy (elbow,
wrist and hand active-
assisted exercises,
isometric contraction
of trapezius and co-
contraction of
rhomboid muscle).
Duration: 7 years.
Cunha et al 2013 Brazil - Case report Uninformed. Uninformed. - Motricity (scale 0/3); Modalities:
Clínica Escola n = 1 (man) Uninformed. - Sensibility (test tube, - Electrostimulation (FES -
Integrada da Age: 39 years hammer and Neurodym III -
Faculdade Santa needle); IBRAMED: f = 50 HZ,
Maria em - ROM (goniometry); dp = 260 ms, ON = 3 s
Cajazeiras- - Perimeter (measuring and OFF = 6 s,
Paraíba. tape); d = 20 min) of
- Quality of life (SF-36). supraspinatus, deltoid,
and pectoralis major
muscles.
- Kinesiotherapy (passive
stretching, passive
and active-assisted
exercises and
strengthening; using
sticks, swiss ball and
dumbbells).
Frequency: 3 times/week,
d = 60 min/session.
Duration:15 sessions.
Khedr et al 2012 Egypt - Randomized clinical trial Uninformed. Unrealized. Clinical: G1: Physical therapy
Department of n = 34; 6-12 months. - Muscular strength (electrostimulation,
Neurology, Age: 16-59 years (MRC - 0/5); ultrasound, heat
Department of Group one (G1) n = 22 (18 - Pain (VAS); therapy and active
Rheumatology men). Average Electrophysiological: exercises) + rMS real
and age = 33.9 years. - Conduction time; (2 types). Parameters
Rehabilitation at Group two (G2) n = 12 (10 - Distal latency (ms) of rMS real:
Assiut University men). Average - NCV (m/s) rMS 1 to relieve pain:
Hospital, Assiut. age = 30.9 years. - CMAP amplitude stimulation at motor
- F-wave latency (ms) threshold, 15 Hz,
10 sec per train with
20 sec inter-training
interval for a total of
1050 pulses (7 trains
de 150 pulses). rMS 2
to increase strength:
(Continues)
PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY
TABLE 2 (Continued)
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

stimulation at 70% of
the motor output, 3 Hz,
10 sec per train with
30 sec inter-training
de SANTANA CHAGAS ET AL.

interval for a total of

1050 pulses.
Application over the
superior trapezius
muscle.
G2: Physical therapy
(electrostimulation,
ultrasound, heat
therapy and active
exercises) + rMS
sham.
Frequency: 5 sessions/
week
Duration: 10 sessions.
Liu et al 2012 China - Department Retrospective review Total avulsion of the brachial Nerve transfers. - Upper limb function Modalities:
of Hand Surgery, n = 28 (men) plexus. (DASH); - Electrostimulation
Huashan Age: 13-38 years. Uninformed. - Pain (NRS - 0 a 10). (uninformed);
Hospital, - Rehabilitation exercises
Shanghai (uninformed).
Both were designed
according to the
method of
neurotization.
Duration: <6 months to
>1 year.
Saliba 2009 United States - Case study Upper trunk. Graft an autologous sural Clinical: Preoperative (almost
University of n = 1 (man). Uninformed. nerve cable to the - Muscular strength daily):
Virginia, Age: 19 years. axillary nerve + spinal (MMT - 0/5); - Ice to the supraclavicular
Charlottesville, accessory nerve was - Active ROM. area;
Virginia transferred to the Electrophysiological: - Kinesiotherapy (passive
suprascapular nerve + - ENM e estudo de ROM exercises for the
Oberlin. conduça~ o nervosa elbow and shoulder
within pain limits, and
for light hand and wrist
functional tasks);
- Semi-sling
Postoperative:
- Semi-sling;
- Kinesiotherapy (passive
and active-assisted
(Continues)
15
TABLE 2 (Continued)

16
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

ROM exercises; active

ROM and manual
resistance for wrist,
hand, and triceps;
pulleys, cuff weights
and exercise bike
were used);
- Desensitization
techniques and skin
mobilization;
- Light neural
mobilizations;
- Electrostimulation
(interrupted direct
current of the motor
points - 8 times/ each
site; 3-4 times/week
àneuromuscular
stimulation);
Frequency: 3 times per
week;
Duration: 2 years.
Marcolino 2008 Brazil - Case report Lesion in the supraclavicular Unrealized. - Pain (VAS); Modalities:
Departamento de n = 1 (man) region. - Shoulder ROM - Neural mobilization;
Biomeca^nica, Age: 29 years Uninformed. (goniometry); - ULTT (median nerve);
Medicina e - Sensibility - Home exercise
Reabilitaça~o do (esthesiometer); guidance;
Aparelho - ULTT (median nerve). - Low intensity laser
Locomotor, therapy (punctual
Universidade de technique; 4 J/cm2)
Sa~o Paulo, Frequency: about 3
Ribeira
~ o Preto. sessions/week;
d = 45 min/session;
Duration: 8 weeks.
Rühman 2008 Germany - Uninformed 37 patients had total lesion. All were submitted to the - Muscular strength Preoperative:
Klinik für n = 80 (69 men e 11 woman); The interval between trauma modified trapezius (MRC - 0/5); - Kinesiotherapy (ROM
Orthopädie, Age: 18-69 years and operation averaged muscle transfer - Shoulder instability exercises and
Unfallchirurgie 6.1 years (0.8-37 years). technique. Before, 62 (groove signal); strengthening muscle -
und (77%) underwent - ROM (degrees) surgical
Sportmedizin, neurosurgery (13 - requirements);
Agnes-Karll- neurolysis and 49- Postoperative:
Krankenhaus reconstruction). - Abduction splint
Laatzen/ (d = 6 weeks,
(Continues)
PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY
TABLE 2 (Continued)
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

Klinikum Region withdrawing for

Hannover physical therapy);
- Kinesiotherapy (passive
and active-assisted
de SANTANA CHAGAS ET AL.

ROM exercises and

strengthening of
rhomboid and
trapezius muscles);
- Postural training;
- Scapular mobilization;
- Lymphatic drainage;
- Massage.
Duration: unclear.
Orsini et al 2008 Brazil - Case Report Upper trunk. Unrealized. Clinical: Modalities:
Centro Universita !rio n = 1 (man) Uninformed. - Muscular strength - Kinesiotherapy
Serra dos Age: 46 years. (MRC - 0/5); (stretching; passive,
Órga ~os - Sensibility - tactile, free and resistive
-Tereso !polis. thermal and painful exercises associated
(uninformed); with functional skills
- Deep tendon training);
reflexes; -PNF (uninformed
Electrophysiological: techniques);
- Changes in ENM. -TENS (uninformed).
Frequency: 2 sessions/
week; 50 min/session.
Duration: 3 months.
Rochkind et al Israel - Randomized double-blind Upper trunk. Uninformed. Clinical: - Low-power laser
2007 Division of placebo-controlled study 24 and 6 months. - Muscular strength irradiation
Peripheral Nerve n = 2, (1 man −22 years e 1 (MRC - 0/5); (wavelength, 780 nm;
Reconstruction, woman - 78 years). - Sensibility (LSUMC) power, 250 mW).
Tel Aviv Electrophysiological: (transcutaneously for
Sourasky - Distal motor latency;- 3 h- 450 J/mm2 to the
Medical Center, CMAP;- NCV and injured peripheral
Tel Aviv F-wave latency. nerve and 2 h - 300 J
University. /mm2 to the
corresponding
segments of the spinal
cord).
Frequency: 5 h/day
Duration: Twenty-one
consecutive daily
sessions
Nogueira et al Brazil - Case study Uninformed (with accessory Uninformed. - ROM (subjective); - Hydrotherapy (warming
2006 Local uninformed. n = 1 (woman). nerve involvement). up, stretching,
17

(Continues)
TABLE 2 (Continued)

18
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

Age: 61 years. Uninformed. - Deep tendon strengthening and

reflexes; cooling down
- Sensibility - exercises);
superficial, tactile, - Home guidances (daily
and painful life activities and
(uninformed); professional life
- Quality of life activities)
(WHOQOL- Bref); Frequency: 2 sessions/
- Pain (VAS) week; 50 min/session
Duration: 18 sessions
Chalidapong at al Thailand - Uninformed Sustained root avulsion. Intercostal nerve transfer to - Electromyographic - Elbow flexion during four
2006 Faculty of Medicine, n = 32 (29 men e 3 women) Uninformed. musculocutaneous activity (ENM - exercises: forced
Chiang Mai Age: 18–40 years. nerve. Medtronic brand)- inspiration, forced
University, Elbow flexor expiration, trunk
Chiang Mai muscle action flexion and attempted
potential. elbow flexion.
Reid and Trent New Zealand - Case study P1-neuropraxia, principally Unrealized. - Muscular strength Modalities:
2002 Local uninformed. n = 2 (men) involving C6 nerve root. (MRC - 0/5). - Kinesiotherapy (ROM
Age: 25 and 39 years. P2 - upper trunk (C5-C6). exercises with rope
Uninformed. and pulley
mechanism;
strengthening of
rotador cuff muscles
with elastics; scapular
estability exercises);
- Manual therapy (soft
tissue therapy to
paracervical muscles
and gentle cervical
mobilizations);
- Acupuncture (to relieve
pain);
- Immobilization (sling);
Frequency: uninformed;
Duration: unclear.
Songchaoren 1996 Thailand - Uninformed. Root avulsion: Spinal accessory - Muscular strength Preoperative:
Faculty of Medicine, n = 216 (208 men e 8 women) Total - 158 -musculocutaneous (MRC - 0/5). - Immobilization
Siriraj. Hospital, Age: 4-58 years. Upper trunk −58. neurotization. - Muscle endurance (Velpeau’s bandage)
Mahidol Time between injury and (repeated lifting of a Duration: 4 weeks
University, operation: 1-12 months. 2 kg weight from 0! Postoperative:
Bangkok. to 90! of elbow - Electrostimulation of 100
flexion for 30 contractions to the
repetitions). denervated muscle;
(Continues)
PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY
TABLE 2 (Continued)
Study location/ Outcomes Intervention
Author/year setting Study design/population Level/time of injury Surgery (instruments) (parameters)

Frequency: twice daily

until a MRC -3 was
achieved.
Framptom 1996 Paper from Third Case report Sustained BPI: C5- C7 Sural nerve grafts for the - Pain (VAS). Modalities:
de SANTANA CHAGAS ET AL.

International n = 1 (man). rupture, and C8-T1 C5-C7 rupture and - Immobilization

Congress of the Age: uninformed. avulsion lesion. intercostal nerve (6 weeks);
International transfer to the ulnar - Mobilization
Federation of nerve for the C8-T1 (uninformed).
Societies for avulsion. - TENS (self-adherent
Hand Therapy, electrodes, one
Helsinki, 1995. electrode was placed
proximal to the nerve
graft and one
electrode over the
most distal point that
he could feel; pulse of
300 ms; application at
home);
Frequency: 8 h/day
Duration: 6 months
Framptom 1986 United Kingdom - Review Uninformed. Reconstructive - Results of surgery Preoperative:
Royal National n = 32 (29 men and 3 women) Uninformed. procedures. were classified as - Kinesiotherapy
Orthopedic Average age: 29,7 years good, moderate or (strengthening of the
Hospital, poor, according muscle for transfer;
Stanmore expectation of each passive stretching;
Middlesex. reconstructive techniques to mobilize
surgery procedure stiff joints);
pre-operatively. - Immobilization (sling);
- Sensory reeducation
(identifying properties
and recognizing
objects; bilateral
activities).
Postoperative:
- Immobilization (3 to
6 weeks);
- Mobilization of stiff joints
(Maitland);
(Continues)
19
 20 PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY

determine if the individuals in these studies underwent

electromyography; SF-36, 36-Item Short Form Health Survey; T, temperature; tDCS, transcranial direct current stimulation; TENS, transcutaneous electrical nerve stimulation; ULTT, Upper Limb Tension Test; VAS, visual
Center System; min, minute; MMT, manual muscle testing; MRC, Medical Research Council; ms, millisecond; n, number of participants; NCV, nerve conduction velocity; NMES, neuromuscular electrical stimulation; NRS,
surgical procedures.
- Reeducation of tendon

Composto; d, duration; DASH, Disabilities of Arm, Shoulder and Hand; ENM, electroneuromyography; f, frequency; FES, functional electrical stimulation; h, hour; I, intensity; LSUMC, Louisiana State University Medical
transfers (several

~o Muscular
Frequency: unclear.

~o magnética; ROM, range of motion; rTMS, repetitive transcranial magnetic stimulation; s, second; sEMG, surface
Duration: unclear.
techniques);

Kinesiotherapy
(parameters)
Intervention

Abbreviations: (SF)-MPQ, (Short-Form) McGill Pain Questionnaire; à, progression; ADL, activities of daily living; ARAT, Action Research Arm Test; c/m, contractions per muscle; CMAP, Potencial de Aça
- Splinting.

Kinesiotherapy was mentioned in 33 studies, mainly in

the postoperative phase. The exercises most com-
monly used included ROM, strengthening, and
stretching exercises. However, it is relevant to highlight
that important gaps on reporting the specific frequency,
duration, and intensity used during the implementation
(instruments)

of these exercises were identified (Tables 2 and 3). In

Outcomes

addition, in three studies18,24,54 the term kinesiotherapy

was used broadly as the intervention method without
further describing which specific therapeutic exercises
were implemented during the intervention.
ROM exercises were performed in all stages of
treatment with varied goals: increasing ROM while
respecting patient tolerance29,44; preventing and reduc-
ing early joint contractures and secondary deformi-
ties28; pain relief55; edema management52; and
Surgery

facilitating upper limb positioning intra-operatively.23,27

ROM exercises were implemented in a progressive
manner (ie, progressing from passive, to assisted, and
finally to active states of motion).44,45 Stretching was
also recommended in the various phases of physical
therapy treatment,7,9,25,28,41,43,46,50,55-58 with an
Level/time of injury

emphasis on passive stretching,7,25,43,56 as these

patients may present poor neuromuscular control.
For muscle strengthening, some authors described
progressive exercises initially with gravity elimination and
Numeric Rating Scale; P, patient; PNF, proprioceptive neuromuscular facilitation; rMS, estimulaça

application of manual resistance, progressing to anti-

gravity and mechanical resistance exercises, according
to the patient’s tolerance.16,29,30,40,41,45,47,49,51,52,55 Other
studies emphasized anti-gravity postures for patients with
Study design/population

MRC < 3.8,59

Some studies have included the prescription of
home-based exercises8,9,16,28,48,50,52,55,59 as one of the
analog scale; WHOQOL-bref, World Health Organization Quality of Life.

rehabilitation stages. Two authors30,40 included strength-

ening exercises for scapular muscles in their treatment
protocol, with the aim of improving stability and facilitat-
ing motor re-education and scapular synergy.

Electrothermal and phototherapy

Study location/

resources
setting

Among the electrothermal and phototherapy resources

mentioned in the included studies, the most commonly
(Continued)

used include TENS, electrical stimulation, biofeedback,

ultrasound, and laser therapy.
The use of TENS to reduce pain was reported in
Author/year

two case reports,9,31 where both patients were also

TABLE 2

submitted to additional physical therapy modalities

(Table 2). Two review articles also mentioned the use
of TENS in painful conditions both at the preoperative50
de SANTANA CHAGAS ET AL. 21

TABLE 3 Physical therapy modalities, goals, and rehabilitation phases presented in the review studies (n = 15)

Author/Year Country Physical therapy modalities and objectives

Verma et al 2019 India Preoperative management

Patient education - to explain the importance of physical therapy motor relearning
program and the significance of their long-term compliance with the treatment
plan.
Postoperative management after nerve transfer
1. Immobilization with a sling (4-6 weeks).
2. Induction exercises for nerve transfers (Donor Activation Focused
Rehabilitation Approach [DAFRA]).
3. Cross-over therapy.
4. Graded motor imagery (three steps: 1. implicit motor imagery involving right-left
discrimination; 2. explicit motor imagery involving imagination of movements
without actually performing; 3. mirror therapy).
5. Electrical Stimulation - MRC = 0 à long duration interrupted galvanic current;
MRC = 1à short duration faradic current (proceed from long pulse to short
pulse gradually as muscle starts getting innervated).
6. Electromyography or Biofeedback - aiming at movement dissociation.
7. Kinesiotherapy - gravity-eliminated training (MRC <2). strengthening with the
therabands and dumbbells (MRC ≥2).
Zhao et al 2019 China 1. Acupuncture - to relieve a patient’s pain and discomfort, increase nervous
excitability and relieve conduction dysfunction, increase stimulation, and
improve patient performance.
2. Fumigation therapy - to promote local and systemic blood circulation and
reduce edema.
3. Moxibustion (at acupuncture points) - to stimulate peripheral nerves, which can
help with neuronal restoration and reduction of muscle atrophy.
4. Therapeutic massage - to increase blood circulation and boost metabolism,
producing an analgesic effect.
Khan and Moore 2016 USA Preoperative management
1. Kinesiotherapy (ROM exercises; strengthening of the donor muscles) - to
maintain ROM and improve edema.
2. Patient education (positioning).
3. Use of splint and compression garments (to reduce pain and edema).
Postoperative management: donor activation focused rehabilitation
approach (DAFRA) - three phases:
Early Phase :
1. Patient education: anatomy - identifying the “donor” and “recipient” muscles
and the involved muscle function; timeline of motor recovery.
2. Home exercise program: rest period - 10-14 days; contract the donor muscle -
10-20 times/hourly; passive ROM exercises - 2-4 times/day; high repetition
with low resistance exercises for the donor muscles.
Middle Phase :
1. Home exercise program: gravity lessened exercises and active-assisted
exercises while simultaneously demanding a strong contraction of the donor;
separation of the two movements (donor contraction to restore recipient
function) - 12 months or until 3+/5 muscle grade; “place-and-hold" exercises
against gravity (initiated with 2+ to 3−/5 muscle strength) - routinely
throughout the day.
2. Aquatic therapy (using floatation devices).
Late Phase :
1. Resisted exercise (using hand-held weights and elastic bands - initiated with
3/5 muscle strength).
2. Electrical stimulation (NMES).
3. Biofeedback (combining with donor activation).
Simon et al 2016 Australia and USA 1. Sensory re-education (recognition of common objects and textures, tactile
stimuli with different sensations, ie, mirror visual feedback).
2. Constraint-induced movement therapy.
3. Exercises.
4. Electrical stimulation (single-dose - supramaximal stimulation for 1 hour at
20 Hz).
5. Transcranial stimulation.
Santos and Carvalho 2016 Brazil 1. TENS - for pain control at the first stages.
(Continues)
22 PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY

TABLE 3 (Continued)

Author/Year Country Physical therapy modalities and objectives

2. Kinesiotherapy (stretching, passive and active exercises) - to maintain ROM

and prevent contractures.
3. Use of orthoses - to prevent development of contractures and limitation of
pathological motor patterns and to expand functional use of the limb.
Relative contraindications: electrostimulation and ultrasound.
Scott 2013 USA Phase 1 - Reducing pain and neurological symptoms
1. Application of moist heat - to reduce muscle spasm and prepare the patient for
ranging exercises.
2. Exercises, twice daily - for ROM and to prevent exacerbation of symptoms.
3. Education about proper body mechanics and limb positioning.
4. Sling.
Phase 2 - Correct musculoskeletal imbalances once symptoms have
improved !80%
1. Continue the modalities as indicated and education.
2. Specific resistance exercises - beginning in a gravity-eliminated plane and
progressing to weights as tolerated.
Phase 3 - Transition to a home exercise program
1. Follow-up with therapy team.
Smania et al 2012 Italy 1. For muscle atrophy - passive muscle stretching; electrical stimulation (prefer
low frequency <20 Hz) and electrical stimulation through subcutaneous
generator with intramuscular electrodes.
2. For pain - Returning the patient back to work and recreation activities; use of
orthoses; TENS (only for postganglionic lesions or in cases with preservation
of some fibers).
3. Sensory re-education - exercises to regain tactile gnosis (perceiving of
different textures and shapes with eyes opened or closed), training the
capacity to localize a stimulus, and also involving attention and memory.
4. Constraint-induced movement therapy - it was suggested repetitive training for
6 hours a day for 2-3 weeks, but studies are necessary in adults with brachial
plexus injury.
5. Treatment of secondary deformities and postoperative care:
5.1 Kinesiotherapy - Exercises to maintain upper limb passive ROM, first gravity-
assisted exercises and resistance and isokinetic machines; passive
stretching; induction exercises after neurotization.
5.2 Use of orthoses - avoiding stiffness and ROM impairment.
5.3 Education about specific care of the injured limb and avoid trauma and lack of
use.
5.4 Ultrasound and TENS associated with scar massage - to improve muscular
contractures and prevent nerve compression.
Coelho et al 2012 Brazil Physiotherapy as conservative treatment
1. Low-intensity laser therapy.
2. Neural mobilization.
3. Kinesiotherapy (stretching and passive, active, and resistance exercises
associated with function ability training).
4. PNF techniques.
5. TENS.
Postoperative management
1. Joint mobilization - to prevent edema and contractures.
2. Kinesiotherapy (stretching and passive exercises).
Havton and Carlstedt 2009 USA Postoperative management
1. Kinesiotherapy: passive ROM exercises and manual stretching - to prevent
contractures; strengthening exercises of partially denervated muscles.
2. Electrical stimulation as an adjunctive therapy - limited utility after a ventral root
avulsion injury and repair.
Colbert and Mackinnon 2008 USA Preoperative management
1. Use of splints, slings, and other supports at the shoulder - to prevent joint
contraction in an undesired position and maintain capsular integrity.
2. Kinesiotherapy (ROM exercises) - to maintain joint motion.
3. Potentially direct muscular stimulation of the denervated muscle.
4. Education about what exercises are needed for postoperative period.
Postoperative management
(Continues)
de SANTANA CHAGAS ET AL. 23

TABLE 3 (Continued)

Author/Year Country Physical therapy modalities and objectives

1. Immobilization.
2. Intermittent ROM exercises - 3-4 times daily to prevent stiffness.
3. Edema and scar management.
4. Electrical stimulation.
5. Neuromuscular re-education (exercises with gravity eliminated motion against
gravity and specific strengthening exercises, use of biofeedback) - to
cognitive recognition of the previous donor of the reconstructed function
followed by relearning for subconscious control.
6. Sensory re-education.
Novak 2008 Canada Postoperative management after nerve transfer
Early phase : regain or maintain ROM regain following the period of
immobilization.
1. Patient education regarding pain and edema control.
2. Immobilization.
3. Kinesiotherapy: ROM exercises - to minimize stiffness in these joints and to
promote neural mobility and gliding and restore shoulder and scapular
mobility.
4. Desensitization exercises - in patients who experience allodynia.
5. Home program - once passive ROM has been regained.
6. Use a hemi-sling - to support and minimizing the glenohumeral subluxation,
until re-innervation of the supraspinatus muscle and restoration of the integrity
of the glenohumeral joint.
Late phase : begins with evidence of muscle reinnervation to motor reeducation
and restoration of muscle balance.
1. Strengthening exercises - begin in gravity-assisted or gravity-eliminated
positions and training scapular muscles even not denervated.
2. Electrical muscle stimulation - to prevent muscle degeneration and to enhance
motor function (efficacy to prevent muscle degeneration remains to be
established).
2.1 Use of biofeedback - to provide immediate feedback and facilitate relearning
by visual and auditory feedback using surface electrodes.
3. Education and encourage to perform activities that require use of both
extremities for self-care, work, and recreation (bimanual tasks).
Kinlaw 2005 USA Preoperative management:
1. Use of orthoses (sling and splints) - to prevent or minimize glenohumeral
subluxation and uncontrolled positional motion of the limb, maintaining normal
capsular integrity, and to minimize the discomfort and give more securitye.
2. Kinesiotherapy (passive ROM exercises) - to maintain joint mobility at the initial
postinjury moment.
3. Education about self-ROM exercises.
3. Electrical stimulation - to specific muscles before neurotization and for
denervated muscles (direct current stimulation - infinite duration ≥300 msec)
Immediate postoperative management:
1. Immobilization with surgeon recommendation.
2. Kinesiotherapy - passive ROM exercises as soon as permitted, to maintain
motion as much as possible (4-6 times a day or more and 10-20 repetitions or
more at each exercise session).
3. Edema control (decongestive massage, compression sleeves or garments,
and elevation as possible).
4. Scar massage - to maintain the scar mobile (with use of some materials).
5. Electrical stimulation - after 3-6 weeks, (direct-current [galvanic] stimulator with
electrodes placed directly in the muscle).
5.1 Electrical stimulation with a portable home unit, 2-6 stimulation sessions a
day, and at each session 30-60 moderately strong contractions (visible).
Re-education of muscle: In case of nerve transfer begins when voluntary motor
unit potentials are seen on EMG or visible contraction is observed.
1. Use of biofeedback (also a portable biofeedback units to use at home) - to
increase the ability to fire the muscle.
2. Use of neuromuscular electrical stimulation - to give the patient the
visualization and sensation of the contraction.
3. Kinesiotherapy - training in the gravity-eliminated or gravity-reduced positions;
increasing training with light weights and antigravity position. Strengthening
(Continues)
24
TABLE 3 (Continued)
Author/Year Country
Tung 2003 USA
Gilbert 2003 France
Frampton 1988 United Kingdom
Abbreviations: EMG, electroneuromyography; MRC, Medical Research Council (degree of manual muscle testing); NMES, neuromuscular electrical stimulation;
PNF, proprioceptive neuromuscular facilitation; ROM, range of motion; TENS, transcutaneous electrical nerve stimulation.
and early58 stages of rehabilitation. In addition, one
review article looking at the use of TENS7 suggested
that its effectiveness for chronic and neuropathic pain
remains inconclusive, with its use being supported only
in cases of postganglionic injuries or sensory fiber pres-
ervation (Table 3).
Although it was widely mentioned as a treatment
option, the vast majority of studies did not provide
any details on the protocols used for electrical stimu-
lation. Three studies only generically mentioned the
use of electrical stimulation20,37,44; others described
its use in partially or totally denervated muscles and
reported the duration of the session24 as well as its
applicability regarding nerve transfer.18,19 Two
PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY
Physical therapy modalities and objectives
using weights and isometric, concentric, and eccentric contractions (daily
sessions for the first 2-3 months).
Sensory re-education: begins when some perception of sensation is present;
but routine inspection of skin is important and the patients must be cautioned
regarding the possibility of pressure sores, and injury from sharp objects,
heat, and cold.
Maintaining passive ROM for all patients for management conservative or
operative.
Postoperative management
1. Kinesiotherapy:
1.1 ROM exercises and limiting immobilization period - to maintain passive ROM
and minimize the formation of scar and adhesions.
1.2 Motor re-education and strengthening exercises - once some clinical
evidence of target muscle contraction is noted - to gradually amplify the motor
and sensory input and for cortical remapping.
Postoperative management after neurolysis
- Immobilization for 2 days and passive exercises starts from the third day.
Postoperative management after nerve grafts
1. Immobilization for 8 days.
2. Kinesiotherapy - active exercises (using nonparalyzed muscles) and passive
exercises start from the third week.
3. Electric stimulation with exponential currents.
4. Use of splints and prostheses.
Early phase
1. Passive ROM exercises - to gain full range of motion and stretching
soft tissues at the same time.
2. TENS (with careful technique and adequate treatment time) - to relieve pain.
3. Use of splint for use at work and for hobbies.
4. Education (home exercise program and self-care for the flail arm; social and
work context).
Middle phase
1. Re-educate reinnervating muscles - using modalities as brushing, icing, PNF,
and progressive resistance exercises.
2. Mobilization of stiff joints and reinforcement of home exercise program.
3. Re-assess pain situation (parameters of TENS) and use of splints.
Late Phase
Preoperative management:
1. Kinesiotherapy: strengthening exercises (muscles to be transferred);
mobilization of stiff joints and stretching of soft tissues.
2. TENS - management of pain.
3. Sensory re-education - to improve steriognosis and localization.
Postoperative management:
1. Motor re-education (five basic principles).
studies mentioned the use of a home-based rehabili-
tation with the use of electrical stimulation sys-
tems.21,41 The type of current used included
functional electrical stimulation (FES) current,43 gal-
vanic current,29 and interrupted galvanic current with
long duration progressing to faradic current with
short-term duration51 (Table 2).
Some of the included review articles looked solely at
the type of current and/or the parameters being
implemented during electrical stimulation8,54 (Table 3).
However, the majority of review articles included overall
suggest that the use of electrical stimulation for the treat-
ment of BPI may have questionable effectiveness in
some cases.52,58-60
de SANTANA CHAGAS ET AL. 25

TABLE 4 Main physical therapy modalities and clinical goals adopted in pre- and postoperative periods

Modalities Goals

Preoperative period
Kinesiotherapy: 1. Maintain upper limb joint mobility, eg, 90! abduction necessary to
1. Passive ROM exercises within pain position patient during surgery.
limits.7,20,22,26,34,39,46 Mobilization in the rigid 2. Maintenance of ROM and strengthening of the remaining muscles and
joints and passive stretching9,22 muscle groups involved in the transfer.
2. Active ROM exercises and muscle
strengthening9,20,22,34,39,48
General use of orthoses7: 1. Minimize lower shoulder subluxation, ensure patient safety, minimize
1. Sling9,22,26,48 pain and discomfort, and avoid uncontrolled positional movement.
2. Hand and wrist splints7,46 2.Circumvent joint contractures in undesirable positions.
Patient education47,48 About limb positioning, the importance and time of physiotherapeutic
motor relearning program.
Use of ice or TENS9,22,26 Decrease pain levels.
Use of compression garments48 Decrease edema.
Sensory re-education: identifying object Increase sterognosy and localization.
properties9,22
Electrostimulation for denervated muscles7,34,46 Uninformed.
Functional tasks of hand and wrist26 Uninformed.
Postoperative period
Initial limb immobilization employing slings or Immobilize the limb.
splints in the immediate postoperative period,
depending upon the technique
used6,7,13,16,17,20,26,28,34,39,47,49
Patient education regarding 1. Prevent trauma and disuse.
1. Pain control, edema, and care with the affected 2. Understanding and identifying the donor” and “recipient” muscles.
and neglected limb6,7,9,50;
2. Surgery and muscle function involved.48
Kinesiotherapy: passive, active-assisted, active, Improve ROM and strengthen muscles.
manual, and weight-resistance exercises and
exercise bike.6,7,13,17,18,20,21,25,26,34,47-51 Home
exercise program.13,17,48
Motor re-education through exercises elaborated Assist the donor nerve shoot if the re-innervated muscle is active and
based on the neurotization method and developing strength and muscle bulk in the recipient muscle.
induced exercises6,7,9,13,15,22,39,47-51
Manual therapy: 1. Enhance mobility and reduce pain.
1. Mobilization of rigid joints9,22,25,50,51 and mild 2. Avoid adhesions.
neural mobilizations26,50 3. Reduce muscle imbalance.
2. Skin and scar mobilization, soft tissue and
fascia manipulation7,25,26,39,45,50
3. Relaxation of hypertonic muscles20,25 and
passive stretching (external shoulder
rotation).6,51
Facilitation of global physiological posture and Stimulate postural awareness, correct the remaining postural muscle
postural training, including balance and imbalances and encourage joint functions.
proprioception20,25
Electrotherapy: 1. Circumvent muscle degeneration and boost motor function.
1. Electrostimulation7,15,17,18,21,25,26,33,45,47-50,52 2. Give immediate feedback on newly re-innervated muscles and enhance
including in a home program7,17,18 post learning.
instructions for use by the therapists.
2. Motor rehabilitation via visual/auditory or
sEMG biofeedback7,13,14,50
Sensory re-education several protocols6,7,13,53 Trigger the disadvantaged cortical areas, maintain and/or restore the
lesion-affected sensory areas.
Desensitization Techniques29,34,36,43 Maintain or ameliorate skin sensitivity and arm proprioception, and for
allodynia patients.
Hydrotherapy17,48 The benefits of a buoyant environment and gravity eliminated can provide
some early active control in the formerly paralyzed muscle.
Abbreviations: ROM, range of motion; sEMG, surface electromyography; TENS, transcutaneous electrical nerve stimulation.
26
Eight studies looked at the effects of biofeedback
strategies on the rehabilitation of individuals with BPI. In
two structured rehabilitation protocols, surface electro-
myography (sEMG)–guided training was found to facili-
tate motor learning after nerve transfers in five patients16
as well as to improve awareness and control of hand
function in six patients undergoing elective amputation
and prosthetic hand.17 In addition, this technique was
also used as part of the conservative treatment of a
patient with incomplete upper trunk injury37 (Table 2).
Some reviews discussed biofeedback use in combina-
tion with donor nerve activation,49,52 and biofeedback
use to obtain greater control of the recipient contraction
and dissociation of movement.51 They also mention the
importance of short sessions to avoid fatigue and the
number of channels needed to activate agonist and
antagonist muscles,59 as well as portable biofeedback
options for patients who undergo home-based biofeed-
back training8 (Table 3).
Two studies used ultrasound as a physical therapy
treatment resource24,44 and only one of them described
the parameters adopted.24 Although an application by
direct coupling in the affected nerve pathway was
described, the authors did not make clear how this appli-
cation was performed in cases of BPI.24 One review indi-
cates the combined use of ultrasound and scar
massage to improve muscle contracture and prevent
nerve compression7; another review alerts to possible
adverse effects as a result of this technique58 (Table 3).
Regarding the use of low-level laser therapy, two
studies presented distinct and well-described protocols
for patients with partial BPI, both as a single therapy22
and as an adjunctive therapy aiming at reducing pain
levels39 (Table 2). As for thermotherapy, heat was more
commonly used when compared to cold, and little detail
was provided about these techniques.24,29,55
Manual therapy
The manual therapy techniques most commonly used
included massage, joint and neural mobilizations, and
the PNF concept.
Massage was used primarily to address secondary
implications associated with the primary injury. Exam-
ples included using massage to prevent adhesions and
to prevent/manage scars7,8,27 and edema,8,23 with
emphasis on the early postoperative stages of rehabili-
tation. In addition, in some studies massage was also
applied to the entire upper limb at the end of the thera-
peutic session due to its analgesic and stimulatory
effects24 (Table 2). Studies on therapeutic massage,
according to TCM review, suggested that benefits of
massage may include increased blood flow, metabo-
lism boost, and analgesia53 (Table 3).
Studies recommended the mobilization of rigid joints
in both pre- and postsurgical periods25,50; as well as
PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY
the recommendations of shoulder27 and scapula23
mobilization, gentle joint distraction,41 and muscle
energy and Maitland techniques.25 Neural mobilization
on median39,47 ulnar and radial nerves47 was also
described in two case reports39,47 of conservative
treatment.
The PNF concept was overall considered as a use-
ful modality for muscle activation in the acute phase
through motor irradiation,47 as well as for re-education
of re-innervated muscles.50 PNF was used in three
case reports9,40,47 in association with other therapeutic
modalities, such as kinesiotherapy, neural mobilization,
and functional training (Table 2). Two of these case
reports investigate conservative treatment approaches
where one of the patients had an upper trunk injury9
and the other an extensive bilateral injury.47 These two
case reports concluded that in both case scenarios,
patients benefited from the motor irradiation technique.
The third case report, on the other hand, investigated a
postoperative treatment approach40 in which stabilizing
reversal, reversal of antagonists, and hold-relax tech-
nique were used, with the latter two techniques being
used in the scapula as well.
Sensory re-education
In the present review, three case reports27,29,37 men-
tioned desensitization as a rehabilitation component.
Nevertheless, no details regarding the intervention pro-
tocols being used were provided (Table 2). A review
article highlighted the importance of this approach for
patients presenting with allodynia.59 The review articles
that discussed sensory re-education techniques
included mainly the recognition of objects and textures,
the identification of their respective properties, as well
as the incorporation of other cortical functions such as
attention and memory7,25,54 during the intervention
(Table 3).
Physical therapy and technology
Assistive technologies have gained popularity with the
use of innovative strategies in the rehabilitation setting.
Four of the included studies in this review32-34,36
described innovative approaches using robotic technol-
ogy, and their findings are described in more detail in
the following paragraphs.
One study32 investigated the use of a wearable
robot in two patients as a rehabilitative strategy follow-
ing elbow flexor reconstruction with intercostal nerve
crossing-to-musculocutaneous nerve. The training pro-
tocol, which also uses biofeedback techniques, aimed
to increase muscle strength in elbow flexion up to a
grade 3 and to promote changes in central nervous
system plasticity. One robot34 was used in three
de SANTANA CHAGAS ET AL.
patients with BPI, as a 12-session game-based inter-
vention program, to improve wrist flexion and extension
movements. .
Similarly, robotic therapy was part of the rehabilitation
program for a patient with an injury (C5-C6-C7) after
undergoing nerve transfers.36 The robot, which also per-
forms kinematic evaluation, used different training modes
(eg, active-assisted to resisted movements) to assist indi-
viduals in horizontal shoulder and elbow flexion/extension
movements. Finally, one of these studies33 reported on a
bionic reconstruction, where the combination of selective
nerve and muscle transfer techniques, elective amputa-
tion, and prosthetic rehabilitation were used to restore
hand function in patients who experienced complete
plexus injury. This rehabilitation process also included the
use of biofeedback to allow the patient to experience pre-
amputation virtual rehabilitation.
DISCUSSION
The results demonstrate that several physical therapy
modalities were used to reduce the nerve damage–
induced complications, as well as to raise the level of
function and task performance of patients with BPI. A
heterogeneous level of methodological strength was
identified among the reviewed studies, with the majority
of them being considered as having low levels of evi-
dence (ie, case reports/reviews).
As an emerging topic, rehabilitation strategies for
people with a BPI have been given increased scientific
attention. An example of that is that publications have
nearly doubled over the past 10 years in comparison to
the previous decade. Although structural outcomes
such as muscular strength, sensitivity, and ROM are
still the most used, function and quality of life are also
becoming essential aspects in the evaluation of individ-
uals with BPI.
Diverse methods and criteria for the classification of
BPI were identified among the studies included in this
review. Even though some authors mention more than
one classification method, some studies failed to report
the level of injury as well as the presence/absence of
surgical interventions. Such information is deemed rele-
vant to facilitate clinical decision-making regarding the
most appropriate physical therapy techniques for each
case, as well as to move the scientific field forward.
The most frequently reported physical therapy
modalities were kinesiotherapy (eg, ROM exercises,
stretching, and muscle strengthening), electrothermal
and phototherapy, manual therapy, and sensory re-
education strategies. Other modalities, although less
frequently reported, were described such as hydrother-
apy, peripheral and transcranial magnetic stimulation,
and assistive technologies.
Kinesiotherapy was the physical therapy modality
most used for the rehabilitation of individuals with BPI.
27
Exercise therapy is among the key elements of physical
therapy programs to prevent loss of and improve func-
tion.61 However, the vast majority of studies failed to
report important exercise prescription parameters, such
as exercise frequency, duration, and intensity. Consid-
ering the wide variety of possible exercises and tech-
niques that could be implemented, the lack of clarity
regarding these specific parameters leads to vague-
ness and therefore challenges reproducibility and
implementation of such therapies.
There seems to be a consensus among authors on
the importance of (a) maintaining and improving ROM
in all stages of treatment; and (b) the need for motor re-
education to improve and facilitate the correct recruit-
ment of the reinnervated muscle and therefore, over-
come secondary issues associated with the complexity
of reconstructive surgery in BPI.10,16,50-52 Understand-
ing surgical goals and procedures is fundamental to
avoiding such issues. In nerve transfers, for example,
when fascicles or branches of a functional distal nerve
are used to reinnervate a muscle or group of muscles,
some muscle functions may be altered and even lost in
order to gain more functional movements.62,63
Several studies mentioned the role of motor re-
education,7,16,49,52,54,59,60,64 with such studies
suggesting that motor re-education should be started
as soon as there is evidence of muscle contraction
(MRC = 1).10,64 Overall, the studies investigating motor
re-education followed a protocol wherein patients were
taught to contract the donor muscle frequently (high
repetition with low-resistance exercises) as an effort to
encourage neural activation and growth52 in order to
achieve the function of the reconstructed muscle.7,49
Once the muscle strength was sufficient to overcome
gravity (MRC ≥3) or the resistance of the antagonistic
and articular muscles, strategies were applied to disso-
ciate the contraction of the donor muscle from the tar-
get muscle.16,52,59
To improve the motor control of the reinnervated
muscle, new motor patterns have to be acquired and
cortical reorganization has to occur.16,52,63 In accor-
dance with the previous literature, we also support that
a rehabilitation treatment for individuals with BPI should
be based and include components of neuroplasticity,
as well as motor learning and motor control.
Some authors also mentioned the strengthening of
the scapular muscles, considering that in order to
regain function of the upper limb, a harmonious move-
ment pattern between that limb and the scapula is
required. As a result of the lesion itself or due to muscle
disuse, weak scapular muscles contribute to the biome-
chanical imbalance causing compensations and insta-
bility during functional activities.59,65 Another aspect
related to kinesiotherapy that was mentioned was to fol-
low an educational approach. The combination of edu-
cation and home-based rehabilitation program is
essential to obtain better functional results8,16,59 by
28
providing guidance on general care for the affected
limb,7-9,50,55,59 thus helping to prevent injuries and con-
sequences of disuse.
When considering electrotherapeutic resources,
although many protocols have been discussed and
some studies have only mentioned their use with no
further detail pertaining to the specific parameters of
treatment, no consensus has yet been reached regard-
ing their usefulness and efficiency for BPI. Therefore,
their real efficacy remains questionable for this popula-
tion.64 None of the studies that described the use of
TENS discussed the best mode or what specific param-
eters were used, making the reproducibility of the inter-
vention difficult.
Neuromuscular electrical stimulation (NMES) aims
to strengthen muscles through activation of efferent
motor nerves, thereby stimulating muscle contraction
when it is difficult or impossible to be voluntarily per-
formed.52,66 Relevant factors such as type of current,
parameters, dosage, stimulated muscles, and position-
ing of the electrodes have not been well described.
Such divergence regarding the use, applicability, and
description of the electrical stimulation parameters was
also observed in the review articles.
The most effective method and time of stimulation
are still open questions when it comes to rehabilitation
protocols for patients with BPI.7 In addition, most stud-
ies on electrical stimulation address peripheral nerve
injuries with axonotmesis, and the consideration that
such therapeutic resources may not apply for cases of
nerve root avulsion, since there is no motor axon avail-
able for stimulation, should be taken.57 Besides being
possibly ineffective for this population, the use of daily
electrical stimulation can inhibit the repair process and
retrograde transport, resulting in a reduction of the neu-
ron’s regeneration capacity.7,67
Although this approach is known to not facilitate
new motor learning patterns by itself, its application can
be conducted with a patient’s cooperation, providing
sensory and motor stimuli for motor learning. Therefore,
NMES may be a viable option as an adjunct therapy for
improving functional recovery,57,59 and especially use-
ful for patients with cognitive and emotional
impairments.52
Biofeedback therapy on the other hand, seems to
be a more promising treatment, as it focuses beyond
muscle strengthening and is an important tool to facili-
tate motor relearning and re-education in the postoper-
ative phase after nerve transfers.15 By providing visual
feedback with EMG, biofeedback therapy allows the
patient to visualize muscle contraction during training,
thus facilitating greater muscle activation capacity and
control over muscle contraction.8,15,16,37,49,59,60
Although there are no clinical trials yet, the results of
some studies16,17 seem promising and suggest that
biofeedback can also increase patient compliance and
motivation.15
PHYSIOTHERAPY FOR TRAUMATIC BRACHIAL PLEXUS INJURY
The low-level laser is widely used due to its direct
and indirect effects, such as, analgesic, anti-inflamma-
tory, and biochemicals factors, resulting from the micro-
circulation stimulus.39,66 In peripheral nerve injuries,
experimental studies suggest that an acceleration of
nerve conductivity and direct irradiation of the spinal
cord has also shown to affect the corresponding
affected nerve.22 However, these findings may not
translate to people with BPI. In addition, considering
the wide variety of indications of thermo-therapeutic
modalities and that patients with BPI may experience
sensory deficits, particular caution should be paid when
prescribing it.
Manual therapy techniques, such as massage and
joint mobilization, were used mainly to treat secondary
implications associated with the primary injury. Mas-
sage was used to prevent/manage the scar tissue and
as a relaxation technique. However, no details were
provided regarding the techniques or parameters being
used. Joint mobilization, in general, plays a preventive
role and aims to maintain joint integrity and to avoid
joint stiffness, as many patients may become inactive
as a result of dysfunction or even go through prolonged
and/or inadequate immobilization. In addition, PNF
techniques were used in different treatment phases
with the aim of improving ROM as well as facilitating
muscular re-education and improve muscle activation.
Considering that patients with BPI with sensory defi-
cits may be more likely to experience cutaneous
lesions and infections, sensory re-education is also a
key aspect of the rehabilitation of individuals with BPI.
However, due to the scarce information regarding the
methodology implemented, reproducibility becomes dif-
ficult. Sensory re-educational programs should include
components addressing cortical neuroplasticity with the
aim of achieving cortical reorganization and improving
the sensory function after reinnervation.6
The influence of technological advances such as
robots and bionic reconstruction in recent rehabilitation
strategies for patients with BPI is also noteworthy.
Although still limited and restricted to specific cases,
such studies were published in the last 5 years and can
offer great potential for further exploration and develop-
ment of a new research field, both for adjunct treatment
in rehabilitation as well as for a more sensitive assess-
ment tool.36
Importance of rehabilitation after BPI
Several studies7,8,24,30,50,54-56 focused on the impor-
tance of rehabilitation after BPI, and some of them have
highlighted the role of physical therapists in such a pro-
cess. Physical therapists are essential to conduct a
patient-focused assessment while being aware of the
individual’s functional limitations and providing appro-
priate treatments at all stages of recovery.25,50
de SANTANA CHAGAS ET AL.
Moreover, studies7,25,31 point out that rehabilitation pro-
grams should consider not only physical aspects, but
also the patient’s social and work environments
throughout the recovery phase, with the aim of training
and encouraging patients to return to their functional
activities. Patient education is an extremely important
approach. By expanding the patient’s knowledge
regarding their health, they take active roles in their
rehabilitation process, becoming co-responsible for
their own treatment16 and being able to achieve better
outcomes.20
Strengths and limitations
This review was conducted with the maximum rec-
ommended methodological rigor and following the
reporting guidelines for Scoping Reviews (Preferred
Reporting Items for Systematic reviews and Meta-Ana-
lyses extension for Scoping Review (PRISMA-ScR)),
encompassing seven databases including gray litera-
ture, without any restriction on language and year of
publication. This review identified important gaps in the
literature about physical therapy modalities used in the
rehabilitation of BPI, which collectively make clinical
decisions and achieving better functional results in
patients with BPI challenging. Regarding limitations,
the authors cannot ensure that all articles were identi-
fied and included in the search, as the EMBASE data-
base could not be accessed.
Although the purpose of this type of review is not to
verify or to prove the effectiveness of a physical therapy
modality to the detriment of others, the scenario built
from this review allowed us to observe and report a lack
of scientific evidence in rehabilitation studies, even with
the increasing recognition of physical therapy interven-
tions for this population.
CONCLUSION
Several physical therapy modalities have been identified
for adult individuals with BPI, including kinesiotherapy,
electrothermal and phototherapy, manual therapy, and
sensory re-education strategies. Kinesiotherapy was the
treatment strategy most commonly used for the rehabili-
tation of individuals with BPI. Even though some studies
lacked a detailed description of the protocol being
implemented, there was a consensus among studies
that maintaining range of motion, even passively, is an
important aspect for all phases of rehabilitation; and that
motor re-education, especially in surgical cases, is
essential to improve motor recruitment and function. It is
important to highlight that the paucity of research with
higher methodological quality and the lack of standardi-
zation on reporting the intervention parameters impose
limits upon evidence-based physical therapy practice in
29
terms of the selection of treatment modalities for patients
with BPI. Therefore, we recommend that future con-
trolled clinical trials should include clearly defined treat-
ment protocols with detailed description of the
outcomes, as well as the physical therapy modalities
and parameters being used. It is essential to incorporate
functional outcomes in the evaluation of individuals with
BPI as well as including physical therapy modalities
based on motor control and motor learning concepts.
This will facilitate the return of the patients’ functional
status, activity, and participation levels.
AC KN OW LED GME NT
ACSC is a Masters Fellow in a Physical Therapy Post-
graduate Program.
CONF LIC T OF IN TE RES T
The authors declare that there is no conflict of interest.
INF O RMA TION
This scoping review was conducted in accordance with
the Joanna Briggs Institute methodology for scoping
reviews.
OR CI D
Alessandra Carolina de Santana Chagas https://
orcid.org/0000-0002-1248-2452
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How to cite this article: de Santana
Chagas AC, Wanderley D, de Oliveira Ferro JK,
et al. Physical therapeutic treatment for traumatic
brachial plexus injury in adults: A scoping review.
PM&R. 2021;1–31. https://doi.org/10.1002/pmrj.
12566