Rehabilitation Following Brachial Plexopathy “Stingers”

1. Rehabilitation Following Brachial Plexopathy“Stingers” Scott Kaylor, PT, DPT, SCS Proaxis Therapy

2. Acknowledgements • Timothy McHenry III, MD • Whitney Wiles, ATC • Matthew Baird, MD • Tom Denninger, PT, DPT, OCS, FAAOMPT • Chuck Thigpen, PhD, PT, ATC

3. Objectives • To identify the prevalence of brachial plexopathy. • To identify the anatomy involved with brachial plexopathy injury. • To describe an evidence-based return-to-play progression that is criteria driven.

4. Prevalence and Incidence • Common in contact and collision sports. • Reported annual incidence of a stinger is between 49-65% in collegiate-level football players over a 4-year career • Recurrence rate 57% • 5-10% of players have more serious injuries with prolonged neurological deficits

5. Signs and Symptoms Common Red Flags Bilateral symptoms or symptoms into more than one limb. Suspect spinal cord involvement If the player remains on the “field of play” the possibility of a spinal cord injury must be considered and ruled out before he is allowed to walk. • Unilateral UE involvement • A traumatic event • Painful sensation that radiates from their neck to their finger tips • Lancinating, burning pain, and dysesthesia usually in a dermatomal pattern. • Weakness/”dead arm”

6. Symptom Duration • Pain typically seconds to hours. • Rarely beyond 24-hours • May experience weakness in deltoid and supra/infraspinatus that typically resolves in 24-hours to 6 weeks.

7. Injury Grading • Grade I • neurapraxia • Grade II • axonotmesis • Grade III • neurotmesis

8. Management Phase 2 Phase 4 Phase I Phase 3

9. Phase I Rehabilitation • Pain control • Restore cervical ROM • Initial muscle facilitation

10. Phase I Rehabilitation • Manual Therapy • Traction • Joint mobilization • Soft tissue mobilization • Modalities • Traction • E-stim

11. Phase I Rehabilitation • 1st Rib Mobilization • Elevated 1st rib due to scalene spasm • Assess with cervical rotation lateral flexion test

12. Phase I Exercise Examples • Supported chin tucks • With biofeedback

13. Phase I Rehabilitation • Neural Dynamics • Sliders vs. tensioners to increase excursion • Do NOT want to increase strain during healing

14. Phase I Rehabilitation • Cervical ROM • Adjust and progress positioning

15. Criteria to Begin Phase II • Full cervical ROM • Resolution of upper extremity symptoms • Not necessarily full resolution of strength • Be able to maintain a supine chin tuck for 30 seconds

16. Phase II Rehabilitation • Improve shoulder mobility as needed • Improve muscular endurance • Incorporate extremity movements with stabilization.

17. Phase II Rehabilitation • Shoulder mobility

18. Phase II Exercise Examples • Quadruped and prone chin tucks • Cervical stabilization with extremity movements • “No Money” • Dying bug • Half kneel chop and lift • Upper extremity exercises • Bands • PNF • Isotonics

19. Phase II Exercise Examples • Shoulder Strengthening

20. Phase II Exercise Examples • Half Kneel Chop and Lift

21. Criteria to Begin Phase III • Be able to hold chin tuck with head lift (without helmet) for 30 seconds • > 4/5 upper extremity strength to be able to perform light-to-moderate upper extremity strengthening without symptoms

22. Phase III Rehabilitation • Improve muscular strength • Implement sport specific activities without contact

23. Phase III Exercise Examples • Cervical Strengthening • Participation in weight lifting with team

24. Phase IV Rehabilitation • Criteria to begin phase IV • Be able to maintain a chin tuck with head lift wearing a helmet > 30 seconds • No symptoms • Full upper extremity strength

25. Phase IV Rehabilitation • Phase IV • Initiate contact drills • Percussion to Erb’s Point • Spurling’s Test • Return-to-play

26. Return to Play Criteria • General RTP Criteria: • Adequate time to heal from primary injury • Absence of underlying conditions that pose undue risk of further injury • Resolution of all symptoms • Full, pain-free ROM • Appropriate cardiovascular fitness • Normal strength • Ability to perform sport-specific skills without symptoms • Same game if complete resolution of symptoms, return-to-baseline ROM and strength profile.

27. Slow-to-No Symptom Resolution • Communication with and referral to team physician • Further imaging • Radiographs • MRI • CT scan or SPECT scan • EMG study

28. Prevention • Identifying those at risk • Post-season questionnaire • Proper tackling techniques • Avoid dropping shoulder • Continued eye contact with opposing player should allow for more upright position • High riding shoulder pads to absorb impact • Protective neck rolls • Prevent excessive lateral flexion & extension of neck • NEVER connect straps from helmet to shoulder pads

29. Brachial Neuropraxia Postseason Questionnaire • Clin J Sport Med. 2012; (22)6

30. Key Points • Stingers are common and history of stinger increases likelihood of sustaining subsequent stinger. • Use criteria to drive rehabilitation progressions. • Do not return to play if have not returned to baseline. • Communication with sports medicine team is important, particularly in the presence of slowly resolving symptoms.

31. Thank you!

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