Phase 2: Corrective (3 weeks to 5-8 months postop)

Key points:
1. The donor nerve has not connected to the recipient muscle YET!.
2. The nerve will be silently growing to the new muscle at a rate of 1 millimeter per day (1 inch per month) - so you will not see any new movement in the recipient arm/hand for several months.
3. The first flickers of movement may be noticed during this phase, but usually only for nerve transfers where the donor was a short distance from te recipient.
4. Rehabilitation goals during this phase are to:
a. Maximize arm/wrist/hand passive range of motion and minimize any joint stiffness in the operated ar.
b. Strengthen the donor muscles.
c. Start visualizing and practicing movements in the operated arm/hand.

Information for patients:   

Imagine/visualize and practice the movement patterns specific to your nerve transfers.  This helps the brain retrain while it is waiting for the nerve to connect to the recipient muscle, and strengthens the brain-body connection.  The goal is to attempt to activate the muscle supplied by the donor nerve simultaneously with the recipient muscle (“co-activation”).

Choose a quiet, calm environment to imagine/visualize these movements for at least 5-10 mins, twice a day (more if possible). It is ok that no movement may be happening, but keep it up!

If you have had nerve transfers on just one arm and your other arm is more functional, you can visualize the movement on the surgical side while performing the same action on your non-operated side.  This has been shown to strengthen the connection between your brain and body.

Common nerve transfers based on the affected movement are listed below:

Shoulder External Rotation

1. Donor: spinal accessory
2. Recipient: suprascapular
3. Cue for co-activating donor and recipient: tennis backhand swing

Shoulder abduction/flexion: 

1. Donor: radial nerve branch to triceps, ulnar branch to flexor carpal ulnaris, medial pectoral nerve
2. Recipient: axillary nerve branch to middle or anterior deltoid
3. Cue for co-activating donor and recipient: do a “snow angel” and straigthen the elbows while simultaneously trying to lift the arms up away from the body

Elbow flexion: 

1. Donor: fascicle of ulnar (FCU) or fascicle of median (FDS)
2. Recipient: biceps or brachialis branch of musculocutaneous
3. Cue for co-activating donor and recipient: bend wrist (FCU) or curl fingers (FDS), while trying to bend elbow

Elbow extension

1. Donor: Axillary branch to deltoid
2. Recipient: Radial branch to triceps
3. Cue for co-activating donor and recipient: Think about “cross country ski poling” - pushing your elbows backwards and thinking about straightening your arms like if you were poling.
4. Strengthening the donor muscle (posterior deltoid) during this phase is helpful.  Try to push your elbow backwards into your arm rests/back rest when seated or into your bed when lying down on your back.  
5. Try to couple this movement with thinking of straightening your elbows.

Supinator to PIN nerve transfer (hand opening):

1. Think about/visualize “Jazz hands” - turning palms up and opening your fingers and thumb

2. Strengthening the donor muscle (supinator) during this phase is helpful.  Try to turn your palm up (supinate) against resistance to work this muscle.  You can do this by holding your operated wrist in a neutral position and resist your operated arm from turning outward with your non-operated arm. If this is not possible, ask a family member/friend or your therapist to hold your operated arm and resist while you try to supinate it.  A universal cuff (see equipment list)  with a light weight can also be used to strengthen your donor (supinator) muscle.  
3. Try to couple this movement with thinking of opening your hand (extending your fingers).

Brachialis to AIN nerve transfer (hand closing):

1. Think about/visualize curling your biceps with your thumb up and making a fist.
2. Strengthening the donor muscle (brachialis) during this phase will be helpful.  Try to practice bending (flexing) your elbow with added resistance.  This resistance can be provided by a theraband, a pulley, a light weight in a universal cuff or with a counter force provided by a friend/family member/therapist.
3. Try to couple this movement with thinking about your hand closing.

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Information for Clinicians:   

Recommend outpatient OT/PT start approximately 4-6 weeks post-op.

Goals of treatment are to:

1. Remind the patient this stage is the Corrective/Silent phase.   First flickers of movement 5+ months post-op.

2. Control edema.

3. Maintain/increase ROM of arm/hand and keep these joints supple.

Start cortical imagery and visualization of the intended movements. Encourage the patient to perform visualization exercises for 5-10 mins BID (more if possible). Pair the donor movement with visualization of expected movement in the recipient muscle.

1. spinal accessory to suprascapular transfer: Strengthen scapular retraction and encourage patient to couple movement with visualization of shoulder external rotation/abduction (“aka tennis backhand”)
2. triceps to axillary transfer: Strengthen elbow extension and encourage patient to couple movement with visualization of shoulder abduction (aka “snow angel”)
3. ulnar (FCU) or median (FDS) fascicle to biceps or brachialis: encourage patient to couple wrist flexion (FCU donor) or finger flexion (FDS donor) movement with visualization of elbow flexion
4. Deltoid to Triceps: Strengthen shoulder extension and encourage patient to couple movement with visualization of elbow extension (aka “ski poling”).

Once flickers of movement are seen, the next phase of rehabilitation can begin.

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