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Nerve transfer surgery is commonly used to treat patients with brachial plexus injuries. However, guidelines on postoperative rehabilitation are not clearly established. Nerve transfers require the patient to relearn how to recruit newly innervated muscle(s), which may not occur naturally or intuitively. Supervised therapy is a valuable resource to guide patients through their lengthy recovery (often >12 months) because target muscle strength is both obtained and functionally used in daily life. This article highlights 10 key principles that provide the foundation for rehabilitation following nerve transfer surgery after a brachial plexus injury. Due to the shortcomings of the current evidence base for nerve transfer rehabilitation, we have included our anecdotal experience to augment the existing literature. It is important to have a collaborative surgeon-therapist relationship to communicate regarding operative details, expected timelines for reinnervation, patient needs, and realistic expectations. We provide examples of how to tailor the exercise program to synergistically recruit both the donor and target muscle action, including how to appropriately advance exercises based on the current level of nerve return. We also discuss the role that fatigue plays in denervated muscle and how fatigue may affect the exercise demands placed on the target muscle during specific stages of recovery., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Patients with a traumatic brachial plexus injury (BPI) have previously identified the need for improved patient education tools, emphasizing the importance of communicating outcome expectations, providing attention to the emotional aspects of the injury and the treatment of pain, and acknowledging the needs of caregivers. We created a journey guide, a BPI-specific educational tool, to address these deficiencies. In this study, we determined the acceptability of the journey guide through surveys of and semistructured interviews with patients with a BPI., Methods: The journey guide was created by a multidisciplinary team focusing on previously defined areas for the improvement of patient education and care delivery related to BPI. To assess the acceptability of the journey guide, we recruited 19 participants from the brachial plexus clinic of our institution and the United Brachial Plexus Network to complete a series of surveys and semistructured interviews. Participants completed surveys regarding their satisfaction with the journey guide, and we conducted semistructured interviews to assess patient BPI experiences and impressions of the journey guide and to seek feedback. Interview transcripts were qualitatively analyzed to determine common themes for improvement., Results: A total of 19 participants with a mean age of 44.7 years were included. The cohort was predominantly male (13 participants) and White (16 participants). The mean time since BPI was 12.9 years, ranging from 2.0 to 39.7 years. On a visual analog scale, satisfaction with the journey guide was given a mean score of 8.4; expected usefulness when a patient is first injured, 8.7; potential for continued use, 7.3; and the fit for the BPI community, 8.8. Qualitative analysis demonstrated a primarily positive view of the guide and identified 4 major themes: (1) visuals and quotes improve clarity and engagement, (2) the journey guide would be most useful immediately following an injury, (3) the journey guide is an effective organizational tool, and (4) it is difficult to orient patients toward future hardships., Conclusions: The journey guide successfully filled a gap in the current care for BPI and was largely deemed acceptable by patients with a BPI. Specifically, participants found the journey guide to be a concise educational resource and an effective organizational tool. Participants also indicated that areas for improvement include the increased use of graphics and images and recognition of the greater BPI community with which patients can engage., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H716 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Given the modest functional outcomes seen after surgical reconstruction and subsequent therapy, increasing attention is being directed to patient satisfaction and psychological aspects of recovery after brachial plexus injury (BPI)., Purpose: To better understand the recovery course after surgical reconstruction for BPI, we used qualitative interviews and focused on common points of frustration for patients., Study Design: Qualitative, interpretive description study METHODS: We conducted semi-structured interviews with BPI patients who were 6+ months post-surgical reconstruction. The interview focused on the patients' experience with BPI, focusing on emotional aspects of recovery. Interviews were transcribed and independently coded by 2 researchers. We used inductive and deductive analysis to organize codes into themes. Once thematic saturation was reached, no additional interviews were conducted., Results: We interviewed 15 BPI patients at median 13 months after surgery (range: 6-43 months). Our analysis revealed: (1) BPI patients expressed variable degrees of participation during recovery, with the indeterminate state of function making it difficult to adjust to life after BPI. (2) The uncertainty while waiting for improved function is frustrating to BPI patients, with many patients expressing concern for activities and moments they are missing due to injury. (3) While many BPI patients feel left out of decision-making, those who felt engaged in the process expressed less frustration and more acceptance of their status., Conclusion: Traumatic BPI patients those who felt engaged in decision-making were more receptive to adjustment to their new state of function. When coordinating multidisciplinary care, measures to encourage patients to feel agency over their outcome and to develop self-management skills have the potential to improve patient satisfaction., (Copyright © 2021. Published by Elsevier Inc.)

Background: There is variability in treatment strategies for patients with brachial plexus injury (BPI). We used qualitative research methods to better understand surgeons' rationale for treatment approaches. We hypothesized that distal nerve transfers would be preferred over exploration and nerve grafting of the brachial plexus., Methods: We conducted semi-structured interviews with BPI surgeons to discuss 3 case vignettes: pan-plexus injury, upper trunk injury, and lower trunk injury. The interview guide included questions regarding overall treatment strategy, indications and utility of brachial plexus exploration, and the role of nerve grafting and/or nerve transfers. Interview transcripts were coded by 2 researchers. We performed inductive thematic analysis to collate these codes into themes, focusing on the role of brachial plexus exploration in the treatment of BPI., Results: Most surgeons routinely explore the supraclavicular brachial plexus in situations of pan-plexus and upper trunk injuries. Reasons to explore included the importance of obtaining a definitive root level diagnosis, perceived availability of donor nerve roots, timing of anticipated recovery, plans for distal reconstruction, and the potential for neurolysis. Very few explore lower trunk injuries, citing concern with technical difficulty and unfavorable risk-benefit profile., Conclusions: Our analysis suggests that supraclavicular exploration remains a foundational component of surgical management of BPI, despite increasing utilization of distal nerve transfers. Availability of abundant donor axons and establishing an accurate diagnosis were cited as primary reasons in support of exploration. This analysis of surgeon interviews characterizes contemporary practices regarding the role of brachial plexus exploration in the treatment of BPI.

»: Traumatic brachial plexus injuries are relatively rare but potentially devastating injuries with substantial functional, psychological, and economic consequences., »: Prompt referral (ideally within 6 weeks of injury) to a center with a team of experts experienced in the diagnosis and management of these injuries is helpful to achieving optimal outcomes., »: Preoperative and intraoperative decision-making to diagnose and plan reconstructive procedures is complex and must take into account a number of factors, including the time from injury, concomitant injuries, preservation of cervical nerve roots, and the availability of intraplexal and extraplexal donor nerves for nerve transfer., »: A team approach is essential to ensure accurate localization of the pathology before surgery and to maximize rehabilitation after surgery, necessitating close contact between the surgical team, physiatrists, radiologists, and therapists., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A830)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Adult brachial plexus injuries result in profound functional deficits, debilitating pain, substantial mental health implications, and extensive economic impacts. Their initial evaluation includes a detailed physical examination, electrodiagnostic studies, advanced imaging, and patient counseling. A team-based approach, led by a peripheral nerve surgeon and including hand therapists, electrodiagnosticians, mental health experts, and pain-management specialists, is used to provide optimal longitudinal care during the lengthy recovery process. The options for the surgical management of brachial plexus injuries include exploration, neurolysis, nerve grafting, nerve transfer, free functional muscle transfer, tendon transfer, arthrodesis, and amputation. When treated within 6 months, the outcomes are favorable for the restoration of essential shoulder and elbow function. Free functional muscle transfer is a powerful tool to address elbow flexion and rudimentary grasp in both primary and delayed settings. The restoration of hand function remains a challenge for patients with complete brachial plexus injury. The purpose of this review is to summarize foundational concepts in diagnosis and management, discuss current trends and controversial topics, and address areas for future investigation., (Copyright © 2021 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: The goals of this study were to assess how preoperative and postoperative patients use their uninjured arm to compensate for adult brachial plexus injury (BPI) and to determine whether the Disabilities of Arm, Shoulder, and Hand (DASH) Questionnaire measures this compensation. Methods: Ten preoperative and 13 postoperative patients were enrolled in this qualitative-quantitative study. During the qualitative phase, patients were asked how they compensated because of BPI; responses were analyzed with grounded theory. During the quantitative phase, patients completed a standard-DASH reflecting the ability to do activities in any way using both arms as necessary, and a qualified-DASH reflecting their estimated ability to do activities using the uninjured arm the way they otherwise usually would. Two DASH scores were calculated (range, 0-100, higher = worse) and were compared with paired t tests. Results: There were 3 categories of compensation: using the uninjured arm more, exclusively, or to position the injured arm so that the hand (if functional) could be used. The mean standard-DASH and qualified-DASH scores, respectively, were 52 and 74 for preoperative patients (difference 22, P < .0001), and 41 and 64 for postoperative patients (difference 23, P = .0008). Conclusions: Patients with BPI report different types of compensation by the uninjured arm which can be discerned by the DASH., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Despite the importance of timely evaluation for patients with brachial plexus injuries (BPIs), in clinical practice we have noted delays in referral. Because the published BPI experience is largely from individual centers, we used a population-based approach to evaluate the delivery of care for patients with BPI., Methods: We used statewide administrative databases from Florida (2007-2013), New York (2008-2012), and North Carolina (2009-2010) to create a cohort of patients who underwent surgery for BPI (exploration, repair, neurolysis, grafting, or nerve transfer). Emergency department and inpatient records were used to determine the time interval between the injury and surgical treatment. Distances between treating hospitals and between the patient's home ZIP code and the surgical hospital were recorded. A multivariable logistic regression model was used to determine predictors for time from injury to surgery exceeding 365 days., Results: Within the 222 patients in our cohort, median time from injury to surgery was 7.6 months and exceeded 365 days in 29% (64 of 222 patients) of cases. Treatment at a smaller hospital for the initial injury was significantly associated with surgery beyond 365 days after injury. Patient insurance type, travel distance for surgery, distance between the 2 treating hospitals, and changing hospitals between injury and surgery did not significantly influence time to surgery., Conclusions: Nearly one third of patients in Florida, New York, and North Carolina underwent BPI surgery more than 1 year after the injury. Patients initially treated at smaller hospitals are at risk for undergoing delayed BPI surgery., Clinical Relevance: These findings can inform administrative and policy efforts to expedite timely referral of patients with BPI to experienced centers., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Patients with brachial plexus injury (BPI) and their family members contribute to Internet discussion groups dedicated to BPI. We hypothesized that a thematic analysis of posts from BPI Internet discussion groups would reveal common themes related to the BPI patient experience, providing topics for patient education and counseling., Methods: Internet discussion boards were identified using the search term "brachial plexus injury support group" in Google, Bing, and Yahoo! search engines. Two discussion boards had substantially more posts than other Web sites and were chosen for analyses. Posts from January 1, 2015, through January 1, 2016, were examined. Using an iterative and established process, 2 investigators (M.T.M. and C.J.D) independently analyzed each post using thematic analysis in 3 steps (open coding, axial coding, and selective coding) to determine common themes. In this process, each post was reviewed 3 times., Results: A total of 328 posts from the 2 leading discussion boards were analyzed. Investigators reached a consensus on themes for all posts. One central theme focused on emotional aspects of BPI. Four other central themes regarding information support were identified: BPI disease, BPI treatment, recovery after BPI treatment, and process of seeking care for BPI., Conclusions: Examination of posts on Internet support groups for BPI revealed recurring concerns, questions, and opinions of patients and their family members. The most common themes related to disease information, treatment, recovery, and the emotional element of BPI., Clinical Relevance: These findings provide a helpful starting point in refining topics for patient education and support that are targeted on patients' interests and concerns., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe our experience using direct muscle neurotization as a treatment adjunct during delayed surgical reconstruction for traumatic denervation injuries., Methods: Three patients who had direct muscle neurotization were chosen from a consecutive series of patients undergoing reconstruction for brachial plexus injuries. The cases are presented in detail, including long-term clinical follow-up at 2, 5, and 10 years with accompanying postoperative electrodiagnostic studies. Postoperative motor strength using British Medical Research Council grading and active range of motion were retrospectively extracted from the clinical charts., Results: Direct muscle neurotization was performed into the deltoid in 2 cases and into the biceps in 1 case after delays of up to 10 months from injury. Two patients had recovery of M4 strength, and the other patient had recovery of M3 strength. All 3 patients had evidence on electrodiagnostic studies of at least partial muscle reinnervation after neurotization., Conclusions: Direct muscle neurotization has shown promising results in numerous basic science investigations and a limited number of clinical cases. The current series provides additional clinical and electrodiagnostic evidence that direct muscle neurotization can successfully provide reinnervation, even after lengthy delays from injury to surgical treatment., Clinical Relevance: Microsurgeons should consider direct muscle neurotization as a viable adjunct treatment and part of a comprehensive reconstructive plan, especially for injuries associated with avulsion of the distal nerve stump from its insertion into the muscle., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)