Jurnal Kesehatan LLDIKTI Wilayah 1 (JUKES), 1 (1) (2021) 28-35

Published by: LLDIKTI WILAYAH 1

Jurnal Kesehatan LLDIKTI Wilayah 1 (JUKES)

Journal homepage: www. lldikti1.kemdikbud.go.id/jurnal

Management of Physiotherapy In Brachial Plexus Injury Post

Neurotization SAN To SSN : Case Report
La Ode Abdul Haris Hijriansyah 1, Prihantoro Larasati Mustiko2, Arif Pristianto3
1
Department of Physiotherapy, Universitas Muhammadiyah Surakarta, Central Java, Indonesia
2
Department of Physiotherapist, RS.Ortopedi Prof DR.R. Soeharso Surakarta, Central Java, Indonesia
3
Department of Physiotherapy, Universitas Muhammadiyah Surakarta, Central Java, Indonesia

Article Info ABSTRACT

Brachial plexus injury (BPI) is an injury to the brachial plexus that
Article history: can cause muscle paralysis in the upper extremities. Based on the
Received: 02-03-2021 data, the proportion of brachial plexus injuries with total lesions (C5–
T1) was 54%, partial lesions (C5-6) 24%, (C5-C7) 19%, and (C8-Th1)
Revised: 16-03-2021
3%. This case report aims to present the physiotherapy management
Accepted: 26-04-2021 of brachial plexus injury.A 23-year-old man with a medical diagnosis
of brachial plexus injury. Previously the patient fell from the
Keywords: bathroom and suffered a blow to the shoulder and fractures in the
proximal 1/3 of the ulna & radial. The patient received the first
Brachial Plexus Injury medical treatment for fracture with ORIF (plate and screw), while
Physiotherapy the shoulder injury received medical treatment after 6 months. The
Program medical procedure is SAN to SSN neurotization surgery. This case
Management report aims to report the patient's condition while undergoing
physiotherapy for 3 times therapy session. The physiotherapy
program provided include ROM exercise, strengthening, stretching,
and release. The results of the evaluation for 3 times of therapy
showed that there was a change in passive ROM, pain, edema and
spasm in the shoulder region. there has been no change in muscle
strength and sensory function. In addition, in the wrist and elbow
region there is an increase in muscle strength. The process of nerve
recovery takes a long time, so there have not been many changes that
have occurred in the patient. The process of nerve growth only
occurs at 1 mm / day. Physiotherapy program given for 3 days
postoperative conditions only aim to reduce problems such as
muscle spasm, edema, postoperative pain, muscle tightness, and
prevent potential problems that will occur. The physiotherapy
program given can reduce secondary problems that occur in the
condition 3 days after brachial plexus injury
This is an open access article under the CC BY-NC license.

Corresponding Author:
La Ode Abdul Haris Hijriansyah,
Department of Physiotherapy,
Universitas Muhammadiyah Surakarta,
Surakarta, Central Java, Indonesia
Email: harishijriansyah@gmail.com

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J. Kes. LLDIKTI Wilayah 1 (JUKES) e-ISSN 2798-6748  29

INTRODUCTION

Brachial plexus injury is an injury that occurs in the webbing of peripheral nerve fibers in the
neck (Cervical) and shoulder area which can cause paralysis of the muscles of the shoulder, elbow,
wrist, and fingers. The brachial plexus is formed from the C5-Th1 nerve roots. The cause of injury to
the brachial plexus can be in the form of excessive stretching, compression, or being exposed to
sharp objects that can cause partial or complete disconnection of the nerves (Heri suroto, 2019). In
general, this nerve damage is known as Wallerian degeneration which consists of neuropraxia,
axonotmesis and neurotmesis (Rotshenker 2017)
The injury can be a partial lesion or a total lesion. Paralysis (motor loss) can occur in the
shoulder and elbow area, if the damage occurs in the peripheral nerves of the upper neck. Paralysis
will occur in the area of the wrist and fingers, if the damage occurs in the lower neck. Paralysis of all
upper limbs, starting from the shoulders, elbows, wrists, and fingers occurs if the damage occurs in
the entire peripheral nerve network (Sakellariou, et al. 2014). Nerve injury will affect all the muscles
that are innervated so that both sensory function (dermatoma area) and motor function (myotome
area) will be disturbed.
Based on the data, the percentage of nerve root involvement with total C5–Th1 brachial
plexus lesions was 54%, partial brachial plexus lesions (C5-6) 24%, (C5-C7) 19%, and (C8-Th1) 3%
(Heri suroto 2019). It usually occurs in men aged 15-25 years. In addition, brachial plexus injuries also
continue to increase in several cities in Indonesia. Approximately 70% of brachial plexus injuries
occur as a result of motorcycle accidents. Previous research has also stated that there are a significant
predilection for male sex and ages between 15 and 25 years for the condition and approximately 70%
of traumatic brachial plexus lesions are caused by traffic accidents involving the use of motorcycles
(Sakellariou, Badilas, Mazis, et al. 2014). In recent literature, the prevalence rate is about 1.2% after
multiple traumatic injuries, and the annual incidence is about 1.64 cases out of 100.000 people (Park et al.
2017)
Muscle injuries after brachial plexus injury, makes the possibility of function recovery due to
brachial plexus injury to be small. Several factors can affect the prognosis of patients with this
condition. These factors include the level of nerve lesions, the level of pain felt, more than 6 months
of getting medical treatment, and the most important thing is the patient's adherence to the therapy.
This has become a problem as well as a challenge in the medical world, especially physiotherapists
related to the rehabilitation program in this case. Based on these problems, a strategy is needed,
including a rehabilitation program for brachial plexus injury. The purpose of this case report is to
review the physiotherapy management of brachial plexus injury

CASE DESCRIPTION

A 23-year-old man who worked as a salesman had an accident. In september 2020, the
patient slipped in the bathroom. The patient's shoulder and forearm hit the bathroom floor. The
incident caused the patient to have fractures in the proximal 1/3 of the ulna & radial. When falling,
the patient is still conscious (not faint). The patient complained of unbearable pain at that time and
decided to go to the hospital right away. After arriving at the hospital, the patient was immediately
given surgery with ORIF (plate and screw) on the proximal ulnar and radial 1/3. There is no suspicion
of previous shoulder problems. After 4 months, the new patient felt the shoulder could not be
moved. Before going to the doctor, the patient is on bed rest and has not had a therapy session for 3
month

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In January 2021, the patient immediately returned to the hospital with complaints of
difficulty moving the shoulder and numbness in the shoulder to the left thumb and index finger. The
patient was then diagnosed with Brachial plexus injury (BPI). The patient was then scheduled for
surgery on March 9, 2021 at the Prof.DR.R.Soeharso Orthopedic Hospital. The operation performed
was spinal accessory nerve to suprascapular nerve (SAN to SSN) neurotization with Transposition of
cranial and peripheral nerves. After the neurotization surgery on day 2, the physiotherapist visited
the patient and the patient still complained of difficulty moving the shoulder and numbness of the
shoulder up to the left thumb and index finger. The patient also still complained of pain in the
incision area. In addition, there were no complaints in the area that had experienced a fracture. The
patient only followed the physiotherapy program 3 times on postoperative days (POD) 1, 2 and 3. In
addition, the patient is willing to have his case appointed as a case report to be reported as learning
material for similar cases, especially those related to the physiotherapy program.

RESEARCH METHOD

Based on medical record data, the patient had undergone SAN to SSN neurotization surgery
with the Transposition of cranial and peripheral nerves surgical procedure. The type of anesthesia
used is general anesthesia. The patient's vital signs and postoperative laboratory results were normal.
Physical examination showed the incision area was in the superior part of the spine of the scapula,
there was massive spasm in the lateral humerus, edema around the shoulder, atrophy of the muscles
around the shoulder, muscle tightness, muscle weakness, and there is a difference in the
circumference of the segments in the upper and forearm with a difference of 2 cm. Sensory
examinations such as pain stimulation tests, sharp dullness, roughness were also performed and the
patient was found to have hyposensation in the C5-C6 dermatome area. Pain measurement was done
using numerical rating scale (NRS) and obtained pain on movement score 5/10. Measurement of
muscle strength can be seen in table 1. In addition to examination of the shoulder region,
examination of the elbow and wrist regions was also carried out. This was due to the previous
medical history, the patient had fractured in the proximal 1/3 of the ulnar and radial (6 months ago).
The functional index is measured using the DASH index but the items assessed are only related to
work (work module). The results can be seen in table 2.
In terms of contextual factors, patients have high motivation to recover, good family
support, and patients do not smoke. This factor is a very beneficial aspect for patients to support the
recovery process. However, the condition that can hinder the patient's recovery is the delay in
getting medical treatment for brachial plexus injury. The patient received neurotization surgery after
more than 6 months post injury. This can affect the patient's future prognosis.

Table 1. Manual Muscle Testing (MMT) Upper Extremity

Movement MMT Interpretation
Grip 4/5 Full ROM with minimal resistance
Palmar flexion-dorso flexion 4/5 Full ROM with minimal resistance
Ulnar deviatio-radial deviation 4/5 Full ROM with minimal resistance
elbow Flexion- elbow ekstension 3/5 Full ROM with against gravity
Supination-pronation 3/5 Full ROM with against gravity
Shoulder Flexion- Shoulder ekstension 1/5 Trace contraction/Flickering contraction
shoulder Abduction- shoulder adduction 1/5 Trace contraction/Flickering contraction
shoulder Internal-external rotation 1/5 Trace contraction/Flickering contraction

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Based on the basic movement function examination, the patient has weakness in the
shoulder region muscles. In line with this, the measurement of muscle strength using the MMT scale
shows that the left upper limb is entirely weak with greater weakness in the shoulder muscle, which
is 1/5 (MMT).

Table 2. DASH Index work module

No Question Score
1 using your usual technique for your work? 5
doing your usual work because of arm
2 4
shoulder or hand pain?
3 doing your work as well as you would like? 5
4 spending your usual amount of time doing your work? 4
DASH score 87,5
*DASH score : ( [(sum of n responses / n) - 1] x 25, where n is the number of completed responses).

The DASH Score item consists of a score of 1 to 5. A score of 1 for no difficulty, a score of 2 for
mild difficulty, a score of 3 for moderate difficulty, a score of 4 for severe difficulty, and a score of 5
for unable. Based on table 4, the total DASH Score for the work module is 87.5 with an average score
of 4 and 5 for each item with the interpretation of severe difficulty and unable.

RESULTS

The intervention given to inpatients aims to provide exercise education in order to increase
functional activities according to patient tolerance and help patients become independent in doing
an activity or exercise. The intervention during POD 1, the patient was only given deep breathing
exercises, passive ROM exercises in the shoulder region in a Supine lying position, and strengthening
for the wrist and elbow regions according to the patient's tolerance. There are not many
interventions that can be given to patients because the patient's condition in POD1 is still dizzy and
nauseated due to the effects of anesthesia. In POD 2, patients are given deep breathing exercises for
pain management and get a relaxing effect. This is in line with the results of research which states
that deep breathing will have the effect of decreasing sympathetic activity so as to stimulate a
decrease in pain perception and provide a relaxing effect (Busch et al. 2012). The patient was given
deep breathing for 3 sessions (1 session 8 counts). For management of edema, the patient is
instructed to half-lying or sitting so that the shoulder is higher than the heart. This follows the
principle of fluid that will flow from a higher area to a lower area, so that edema is expected to be
reduced.
In addition, patients were given passive ROM exercises in the left shoulder region (flexion,
extension, abduction, adduction, endorotation, exorotation) according to the patient's tolerance.
Each movement is repeated 3 times. This passive movement is given because the patient is unable to
actively move (MMT 1/5) and to maintain range of motion from stiffness in the shoulder joint. On
the lateral side of the humerus muscle that experienced massive spasm, a release was given to reduce
the massive spasm. In the elbow, wrist and finger regions, active ROM exercise (each movement is
performed 3 repetitions), strengthening exercise, and stretching. At the end of the training session,
the patient was given another breathing exercise. All exercises given are adjusted to the patient's
tolerance and condition. The condition of vital signs is still a top priority for determining the dose of
exercise. The intervention given during POD 3, was the same as the intervention given during POD 2
with the exercise dose being progressively increased but still taking into account the patient's

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tolerance and condition. In addition to the shoulder, elbow, wrist and left finger regions that are
given training, the regions that do not have problems are also given training that aims to maintain
the quality of other regions so as not to experience problems.

Table 3. Evaluation of the shoulder region during therapy sessions

Shoulder
PROM MMT Pain on Oedem Spasm Sensory
POD
movement
Limited range
Hyposensation &
of motion of
1 1/5 5/10 + + (triceps) Numbness of
the shoulder
lateral humerus
joint
Hyposensation &
Same as
2 Same as POD 1 1/5 3/10 reduce Numbness of
POD 1
lateral humerus
Hyposensation &
Increased but
3 1/5 3/10 reduce - Numbness of
not significant
lateral humerus

Table 4. Evaluation of the elbow & forearm region during therapy sessions
Elbow & Forearm
POD AROM MMT Pain Oedem Spasm Sensory
Hyposensation &
1 No limitations 3/5 - - -
Numbness
Maintanance
Hyposensation &
2 Range of 4/5 (load 1 kg) - - -
Numbness
motion
Maintanance
Hyposensation &
3 Range of 4/5 (load 2 kg) - - -
Numbness
motion

Table 5. Evaluation of the wrist & finger region during therapy sessions
Wrist and Finger
POH AROM MMT Pain Oedem Spasm Sensory
Hyposensation &
1 No limitation 4/5 (load 1 kg) - - - Numbness finger 1
&2
Maintanance Hyposensation &
2 range of 4/5 (load 2 kg) - - - Numbness finger 1
motion &2
Maintanance 4/5 (minimal Hyposensation &
3 range of resistance from - - - Numbness finger 1
motion therapist) &2

Based on the results of the evaluation for 3 times (table 3), the aspects that appear to have
changed in the shoulder region are aspects of passive ROM, pain, edema and spasm while aspects of
muscle strength and sensory do not change. This happens because in the condition of the brachial
plexus injury the condition of the nerve ruptures so that nerve connectivity is disrupted. This causes
the patient to lose the ability to motor aspects (motor loss) and impaired sensibility (Sakellariou,
Badilas, Stavropoulos, et al., 2014). Although in this condition the patient has undergone
neurotization surgery, the changes cannot be immediately seen because the nerve reconecting occurs

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only 1 mm/day and the conductivity and nerve recovery aspects require a long time (Heri Suroto,
2019).
The increase in passive ROM can occur because passive ROM exercises and stretching have
been given for 3 meetings so that the muscles in the shoulder region that experience tightness can be
slightly stretched. The stretching of the muscles that experience this tightness makes the range of
motion of the joints a little wider. In addition, the postoperative pain condition that can be reduced
is one of the effects of giving breathing exercise. This exercise can provide an effect to relieve pain.
This is in line with the results of research which states that postoperative patients will experience
disturbances in the endogenous opiate system in this case endorphins-encephalin which is a natural
pain reliever. breathing exercise, has the effect of stabilizing the performance of endogenous opiates
(endorphins-encephalin) so that the perception of pain can be reduced (Asta and Rini 2018). In
addition, the patient is also taking pain medication. The combination of pain relievers and the
provision of breathing exercise is one of the factors that reduce pain in this patient.
Edema that occurs in postoperative patients is a physiological inflammatory response due to
the incision wound. This condition is very common in postoperative patients. One of the
interventions given is that the patient is positioned sitting so that the shoulders are higher than the
heart. This aims to reduce the edema in the patient's shoulder because the fluid will flow from a high
place to a low place. The condition of spasm on the lateral side of the humerus also decreased after
the intervention was given for 3 times. This is in accordance with research which states that
myofascial release is effective for reducing muscle spasm by stimulating mechanoreceptors and
vasomotor so that circulation becomes smooth and can accelerate the disposal of the body's
metabolic products (Mishra et al. 2018)

DISCUSSIONS

This case report presents evidence-based physiotherapy examination and management of a

23-year-old patient with post-neurotized brachial plexus injury. A review of evaluations, both
objective and subjective, shows that physiotherapy programs and interventions are very helpful in
improving the clinical status of patients. Rehabilitation programs for brachial plexus injuries require
a very long time, this depends on the regeneration process of the nerves that are injured (Heri suroto
2019). This long recovery process can lead to potential problems that can occur in patients with
brachial plexus injury conditions. These potential problems include contractures, atrophy, joint
stiffness, muscle weakness, and muscle tightness (N.Smania 2014). To avoid this, physiotherapists
can provide long-term programs to minimize potential problems that can occur due to these
conditions. In the management of this case, the physiotherapy program and intervention were
adjusted to the patient's condition and tolerance for POH 1, 2 and 3. In addition, the patient was also
advised to do routine physiotherapy after being discharged from the hospital so that the healing
process could be faster.
The condition of the lesion will affect the patient's recovery process sooner or later. Based on
the level of the lesion, brachial plexus injury is divided into 2, namely lesions at the preganglionic
and postganglionic levels. Preganglionic lesions tend to be more severe than lesions at the
postganglionic level. The condition of postganglionic lesions, usually can spontaneously regenerate
depending on the severity of the lesion (Saliba et al. 2015). In this patient, it was known that the
lesion level occurred in the postganglionic suprascapular nerve and spontaneous regeneration did
not occur, so it was decided to perform SAN to SSN neurotization surgery. In addition, the patient
received surgery after >6 months post injury, this is a factor that can hinder the patient's recovery

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process. The literature states that functional recovery is rare after 3 or 4 months after loss of function
and for the condition of postganglionic lesions on the suprascapular nerve very few spontaneous
regeneration occurs (Martin et al. 2019) In addition, other studies have also reported that only about
35.3% of patients underwent exploration procedures show good functional results (Rich, Newell, and
Williams, 2019). Pain is one of the most negative factors on the quality of life of patients with BPI.
Pain is a common symptom after BPI which was recorded as much as 71% (Treede RD et 2008). Pain
after BPI is usually neuropathic, with reported rates of neuropathic pain being as high as around 95%
(Ciaramitaro 2017) . Usually caused by trauma or traumatic neuropathy to the musculoskeletal
system, but other types of pain are also associated with nociceptive pain (Upadhyaya 2017)
Postoperative rehabilitation aims to target shoulder function at 90 degrees to be functional and
pain-free (Saliba et al. 2015). The anticipated recovery time is 1 to 2 years considering that nerve
regeneration and reinnervation occur at a rate of about 1mm/day (Heri suroto 2019). Physiotherapists
provide education to patients about the recovery process and rehabilitation programs. The patient
follows all postoperative therapeutic procedures, and understands that recovery will be a long
process. Further research really needs to be done so that there are more variations in the
management of physiotherapy in this condition and can be a rationale for implementing a program
or intervention in the future.

CONCLUSION

Physiotherapy treatment is very necessary for the long-term function of patients with
brachial plexus injury. Although this case report has not seen significant changes in the patient
because it is still in the 3 day postoperative stage, some of the complaints experienced by the patient
can be minimized. Long-term therapy is needed considering this condition requires a very long
recovery time. Therefore, adherence and routines in the therapy process must be optimized to get a
better quality of life and function for patients.

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