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The main objective of the research consists in providing evidence that a long-term rehabilitation protocol is favorable for the patient. In adult brachial plexus (BP) palsies, after several surgical attempts, the lack of results in the upper limb's functionality leads to less compliance to rehabilitation therapy. The upper limb's functionality of 22 patients with posttraumatic operated chronic BP paresis (either on the right or left, regardless the dominant limb) was assessed retrospectively. The patients were evaluated regarding MRC scaling, dynamometric tests and electroneuromyographic examination. All patients have gone through at least one rehabilitation interval (10 days) after an initial evaluation, and were evaluated again, by same methods, at a second session, at least 6 months later, but no more than one year. Mild and inconstant improvements were obtained in a total of 9 patients, especially in better dynamometric results and improved amplitudes of motor and sensory action potentials. The electrodiagnosis correlates with dynamometric parameters (muscle strength) and slight amelioration of the motor deficit. Given the small sample size as a limitation, as well as no standardized therapeutic protocol, it should be noted that the 9 patients were the only ones who either attended more than one interval or did more procedures as frequency in time (more often meaning 3 times weekly for 6 months, in 6 patients). Although the most frequent procedures were neuromuscular electrical stimulation (NMES) and proprioceptive neuromuscular facilitation (PNF), the results suggest that regardless of the techniques, the more active patients had better results. Proving the need for long-term rehabilitation, even contrary to the less visible results, can be the trigger point for future research and therapy strategies, as the results suggest central mechanisms involved, adding the cortical ongoing plasticity into the equation. [ABSTRACT FROM AUTHOR]

Background: Correlations of Transcranial magnetic stimulation (TMS) mapping of the cortical area and electromyography (EMG) + dynamometric testing may demonstrate active neuroplasticity events that are reliant on rehabilitation therapy (RT) compliance in adult postsurgical brachial plexus (BP) injuries. Material and Methods: On the right (dominant) arm of two patients with chronic operated BP lesions, we evaluated the progress of functional recovery. The traumatic event was dated more than 10 years ago for both patients. The first patient (male, 50 years old) and the second one (female, 58 years old) had a history of several microsurgical neurotiza-tion and muscle transfer procedures, with less amelioration of the motor deficit, especially re-lated to elbow flexion (MRC 1/5 and 2/5, respectively). We followed up their evolution by EMG parameters, dynamometry, MRC scaling, and TMS. The motor region of the limb was mapped using TMS to assess the amplitudes of the motor evoked potentials (MEP), on a 4-axis protocol. The patients were assessed twice, with the second examination performed after RT had just fin-ished. TMS findings were compared with EMG and dynamometric results. Results: Higher MEP amplitudes were associated with improved MEP latency during stimulation of the left cerebral hemisphere's cortical area, as well as at the cervical level. EMG findings, both nerve conduction and needle EMG studies showed nonsignificant improvements, as well as muscle strength (as measured by the hydraulic dynamometer). The best results for the first patient showed an in-crease in MEP's amplitude increase from 1.08 mV to 1.49 mV (in the hotspot), which correlated with measurable latencies, as compared to the first TMS (when no response was obtained at cer-vical stimulation). The second patient also had improvements in latencies: from 37.1 msec. to 36.3 msec. (cervical stimulation with recording at bicipital level) and from 39.2 msec. to 37.9 (cervical stimulation recording at the first interosseous), with a hotspot increase from 1.35 mV to 1.98 mV. The results demonstrate cortical region reactivity in regard to therapeutic techniques. Central modifications do not correlate with visible EMG and dynamometric improvements. Pa-tients with traumatic BP palsy may receive several microsurgical reconstructive procedures, nevertheless, the rehabilitation of the upper limb's functionality may sometimes still be limited. This increases the risk of discontinuity of the neuromotor RT. We aim to prove that in spite of little correlations with clinical and EMG findings, mapping the cortical area using TMS provides proof of ongoing neuroplasticity phenomena, dependent on adherence to RT. Conclusion: The evidence of continued brain activity supports the requirement for long-term adherence to treatment guidelines and long-term study protocols. [ABSTRACT FROM AUTHOR]

Nerve-transfer surgery is the treatment of choice for traumatic brachial plexus injuries (tBPIs). Combined electromyography (EMG) follow-ups and results obtained by transcranial magnetic stimulation (TMS) may provide useful follow-up of rehabilitation outcomes of elbow flexion in C5-C7 tBPIs. A total of 11 patients with complex tBPIs, operated by the Oberlin surgical technique, were assessed clinically (British Medical Research Council's score—MRC) and by EMG + TMS after undergoing neuromuscular electrical stimulation and proprioceptive neuromuscular facilitation. Dynamometer quantitative muscle strength (DQMS) was also assessed for overall grip strength evaluation. Six patients continued rehabilitation three times a week, whereas five patients did not follow recommendations for continuous physical therapy (PT). All patients were assessed after 6 months as planned. Following a 6-month PT protocol, clinical improvements correlated with decreases of the Motor Evoked Potential (MEP) latency recorded at the first dorsal interosseous muscle, biceps brachii, and cortical level in the sublot group with continuous PT protocol compliance. We obtained significant amelioration of MEP latency and needle EMG signs of amelioration in these six patients. These cases also correlated to the MRC improvement in elbow flexion, as well as DQMS parameters. TMS parameters also mildly and inconstantly improved in the other five patients who limited themselves just to PT after surgery; however, there was no correlation with the EMG findings or MRC scaling. PT influences the cortical representation within the motor area of the upper limb when performed continuously. The electrical signals within the motor cortex promote the utility adherence to long-term PT protocols. [ABSTRACT FROM AUTHOR]