BRACHIAL PLEXUS

Brachial plexus is the nerve network that innervates shoulder girdle and free upper sides.Basically , occurs by anterior branches of C5-8 and T1 spinal nerves.Some fibers which get resources from anterior branches of C4 or T2 spinal nerves may joint this plexus.If C4 fibers take part in the plexus “ peripheral brachial plexus “ or T2 fibers join in the plexus “ postfix brachial plexus “ terms are used.

The brachial plexus is the most complex plexus in the peripheral nervous system.This plexus that occurs in between the M.sclenius anterior and medius , consist of rami,truncus,divisiones and fasciculus.Lateral,medial and posterior cords go forward to inferomedial of corocoid process from 1/3 lateral of the clavicle.The cords divide into 5 terminal branches at the level of M.pectoralis minor; ulnar,radial,median,axillary and musculocutaneus.

The posterior braches of 3 truncus unite and create the fasciculus posterior.

The anterior branches of truncus superior and medius unite and create the fasciculus lateralis

The anterior branch of truncus inferior creates the fasciculus medialis.

BRACHIAL PLEXUS INJURIES

 1-TRAUMATIC REASONS 

A- Close contact sports : Many football players experience burns or stingers in the brachial plexus, which can occur when nerves are stretched beyond their limits during collisions with other players. 

B- Difficult Births : Brachial plexus injuries may continue in newborns and the reasons may related with high birth weight,breech presentation or long term birth.If a baby’s shoulder pinches in the birth canal , the risk of brachial plexus injury increases.Most of the time , the upper nerves are injured which is called the Erb paralysis.

Various types of trauma can cause brachial plexus injuries, including motor vehicle accidents, motorcycle accidents, falls, or gunshot wounds.

C- Tumors And Cancer Treatment : Tumors can grow or press on the brachial plexus or spread to nerves.Radiation therapy on the chest may be harmful to plexus.

2- AXILLARY ARTERY ANEURYSM 

As a result of aneurysm, compression of anterior branch of T2 may occur due to cervical rib and postfixed plexus. 

3- BREAST CANCER 

It can be damaged as a result of radiation therapy , or it can damaged by infiltrating the malignant cells of breast cancer. 

SYMPTOMS 

The signs of the brachial plexus injury can vary greatly depending on the severity and location of damage.Generally , only one arm is affected. 

LESS SERIOUS INJURIES 

If the brachial plexus nerves are stretched or pinched , in the close contact sports like football and wrestle , occur small injuries in general.These are called the stinger or burner and the following signs may occur. 

• Electric shock sensation 
• Numbness and weakness in the arm 

Generally , these symptoms take a few seconds or minutes but in some people take days. 

MORE SERIOUS INJURIES 

More severe symptoms result from injuries that severely injure or even tear or rupture the nerves.The most serious injury ( avulsion ) occurs when nerve root tears from the spinal cord. 

SIGNS 

• Weakness or inability to use certain muscles in the hand,arm or shoulder. 
• Lack of sensation and full motion in the arm 
• Severe pain 

TREATMENT 

Treatment depends on the severity and type of injury and other factors.Only the stretched nerves can recover without other treatments. 

Doctors may suggest the physical therapy due to the keeping joints and muscles working properly and protecting ROM . 

The surgical treatment should be done within 6 and 7 months after the injury. The succes rate is low in the later surgeries. 

The nervous tissue grows slowly , so it takes several years for the success of surgery to be known. 

During the recovery period, you should keep your joints flexible with an exercise program.Splints can be used to prevent the inward curling of your hand. 

GOALS OF PHYSICAL THERAPY 

• Improving strength , endurance and coordination. 
• Protecting the ROM with passive movements , exercise therapy , splinting and protecting denervated dermatomes. 
• Functional education and adaptation devices. 
• Pain control with TENS and acupuncture. 
• Reducing the chronic odema with education, compression clothes and massage therapy. 

Surgery is an option for severe brachial plexus injury and can be performed at specific interval time.Aim of the surgery is the regaining functions with surgical repair. 

Physiotherapists are important at regaining strength , coordination , flexibility , ROM functions with using splints after surgery.Patients should know that the rehabilitation period will takes years , not weeks. 

JOINT ROM AND MUSCLE STRETCHING 

Stretching and range of motion of the upper extremity joints by a therapist or physician can help prevent significant contracture.Joint contractures limit ability of muscle strength due to nerve recovery.After a typical brachial plexus injury , shoulder joint shrinks at internal rotation and adduction.Forearm may be limited at supination and pronation significantly.Weakness in hand and fingers may causes to stay in a flexible position of fingers. 

Stretching is the most efficient when it is applied at several times a day or applied with heat or ice for relaxing muscles , tendons and limiting the pain.

HELPING PROTECT JOINTS AND PROVIDING FUNCTIONAL SUPPORT

Weakness of shoulder muscles may cause the sublocation ( partial dislocation ).Supporting the arm in a suitable position during daily activities can decrease the pain.

Orthosis that using for preventing thumb, finger,wrist or elbow contractions can be prescribed.Some special orthosis can be used at night to keep the extremity at a specific position.

MUSCLE STRENGTHINING AND OTHER TREATMENTS 

Shoulder and upper exteremity strengthining exercises can include the resistance bands in general. At the discretion of your therapist, your home program may also include electrical stimulation (e-stim), which can be done at home after basic instructions. 

Gloves or other restraints may be used to support the affected person’s use on the unaffected side (restraint therapy). In addition to strengthening weak muscles, mirrors can be used to trick the eye and brain into normal function on the affected side (mirror therapy) to reflect the movements of the unaffected limb onto the affected one. 

REDUCING PAIN TECHNIQUES 

Pain may be an important complication that limits using the affected extremity , even the patient uses medications. 

At home, patients can use desensitization techniques such as water baths with contrast-warm temperatures, stroking or touching the arm with different tissues to reduce pain. 

TENS and medication treatment plans may reduce the pain.

NEWBORN BRACHIAL PLEXUS PALSY AND REHABILITATION (  NBPP ) 

NBPP occurs by traction during the birth and causes the losining function at the affected side.The classification of NBPP is done according to this limitations. 

• Duchenne Erb Syndrome ( upper extremity palsy C5-6 ) is charecterized by degenerated shoulder abduction , external rotation and elbow flexion but hand functions are protected. 
• Degenere Clumpke Syndrome ( lower brachial plexus palsy C7-T1 ) is charecterized by degenerated hand and wrist functions. Claw hand deformity is seen. 
• Total brachial plexus palsy ( C5-T1 ) is charecterized by a flask arm and ocular disability.All these signs are called the Horner’s Syndrome. 

Conservative treatment in NBPP is possible with early diagnosis and close follow-up 2 -3 weeks after the birth of the baby. A multidisciplinary approach should be followed in conservative treatment (physical therapists, clinical neurologists, neurosurgeons, physiotherapists). The treatment applied by physiotherapists should include components such as soft joint movements (such as active/passive mobilization exercises), sensory stimuli, stretching, increasing the sensory input by touching different surfaces, increasing the sensory input of the injured arm with vibration and brushing techniques. Sensory stimulation is just as important as motor stimulation. Electrical stimulation is complementary to conservative treatment. It restores the tone and strength of the affected muscles and improves the mobility of the affected arm. Therapy sessions should be carried out several times a week, repeated at home as often as possible, for example, after each meal. Studies have shown that conservative treatments performed by physiotherapists reduce the need for surgical interventions.  

There are several tools used to complement conservative or surgical treatments, these are electrostimulation devices, botulinim toxin injections, thermoplastic splints (anterior and posterior splints control excessive ulnar flexion and deviation, and anterior splint simultaneously controls thumb adduction). 

Electrostimulation provides recovery of muscle strength and nerve regeneration. It maintains joint range of motion and prevents atrophy. Injecting botulinum toxin into the healthy antagonist muscle has proven to be an effective method to prevent muscle imbalances, cocontractions and muscle contractures. Its purpose is to restore muscle balance and develop affected muscles. Botulinum toxin is important in improving wrist functions (such as flexion and supination). · Splints improve the wrist functions of children and enable wrist extension. Some splints can be used while sleeping, while more functional ones can be used during daily activities. Even an hour-long session a day can increase mobility, functionality, range of motion, speed and manipulation of the hand. As a result, rehabilitation methods used for NBPP are diverse and more scientific research is needed on this subject.