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Hi all-
I need your experience with brachial plexus avulsions. I am working with a 5 month old Goldie who launched out of a moving car. She has no sensation or reflexes and no active motion. she seems to have, although it is getting better, alot of soreness in her neck and her AROM is quite limited. I am working on ROM and stretching throughout the limb, started some NMES to the triceps with no response so far, soft tissue massage, laser and cold to the neck and scapula, and am trying to encourage some weight bearing via positioning and hand over paw stretching into placement. I am starting proximal for the NMES and want to try the carpal extensors also at some point soon; what would be most effective if indeed there is some neuro/motor ability to stim and tap into? Also what kind of parameters are optimal for NMES to begin to see a change if there is to be one?
What to expect with such a young dog? When might I see some action if it is a stretch injury vs a complete avulsion? (no MRI has been done). What is used to protect the dorsum of the paw from injury as it drags? Is amputation the answer when there is no return after 4-5 weeks? Bracing I imagine would require some proximal motor control and strength to be effective.
She is such a cutie and the owners are distressed and hopeful, but not too hopeful. Thankyou!

Hey there,

So, these can be tough cases because you don't know what exactly you are dealing with... could be an avulsion right from the spinal cord! So, I look for some SIGN of responsiveness within 2 months. Nerves grow 1mm a day or up to 1 inch a month. You don't say how long ago the injury was.

I use my e-stim for diagnostics only. If you are not getting a response, it is of no use. Additionally, it does not necessarily help with nerve regeneration even if you were to get a response. So, the rule of thumb is just to use it for testing. And to do so, I recommend setting it at 2 - 5 pulses per second (Hz), with the highest pulse width your machine will allow (250 - 300 usec). Then make sure you have adequately 'gooped' two spots with gel on the same muscle and test. Move it around a little. The proximal muscles will come first (if they are going to). So you'd see triceps before carpal extensors. And lack of muscle activation on carpal flexors could indicate a nerve root issue over a radial nerve issue... since the flexors are ulnar & median N supplied.

If you had triceps, you could make a splint that supports the carpus and foot... without elbow control however, you are just going to have to protect the foot with a bootie or the like.

I would laser the living daylights out of the neck and cranial T/S (C6 - T1/2).

Fingers crossed for this little one.

Laurie

Thank you so much Laurie- this was very helpful. I will "laser the s_ _ t" out of it as I believe I have seen it written before...I have a Spectravet....so neck & cranial TS spots....30" secs each? (How deep is puppy tissue? I always have to look at a metric ruler since I am an American and imagine from there).
I will see her tonite and give it a go, trying to see her 3x-4x weekly fortunately she is only 5 miles from me!

Ha! Yes, I have been known to say "Laser the s**t out of it!" I do everything at 40 sec, any Hz, with my 500mW laser... thus delivering 10J/cm2. And then when the tissue is deep or the condition is chronic, I simply to MORE spots and do over the same spots 3 or 4 times. That's about what I would suggest with the puppy, do 3 - 4 reps on each side of the neck and some at the top of the withers (T1-2) as well. Maybe a couple of zaps into the axilla as well to target that aspect of the brachial plexus!

Good luck! Laurie

Hi again-and yes Laurie- I have been lasering pretty much just as you suggest with my 500 mW laser-at 30 sec but can boost that to 40. I d/c'd NMES for a few weeks but then last week tried again and the puppy did not like it at all which I take as a good sign! I consult with Amie frequently who felt that even some superficial sensation is a good sign. I am also trying to find the balance between stretching the elbow/carpus to allow for more flexion if there is no mm return, and more aggressive work there for fuller ROM if there IS return to be able to get weight bearing at some point. Doing some assisted wt bearing on the fitbone and disc at present too.
At this point there is no chewing/self mutilation- and the pup gleefully meets me at the door and lays down on her mat for her treatment! Owners are good with ROM, Functional positioning corrections, and the pup wants to do the stairs herself which is not allowed yet and I do some hand over paw help going up. Giving the whole thing time at this point, it has been 4 weeks, I feel glad to have gotten in there 3x/ week at week 1. Any thoughts are welcome!

Wow!
So tell me where you are testing the NMES? Triceps? Forearm - flexors or extensors? What if you place it under the foot?
I would consider rigging something up as a standing/walking brace using thermoplastics. Might be a bit early or too troublesome just yet however... but I'd have it in the back of my mind. Hmmm...
Any elbow anti-gravity control noted yet?
I have one dog that had a brachial plexus avulsion secondary to use of using forceps to pull on his front leg to get him out at birth. He never did regain below the elbow, and his carpus and elbow thickened and essentially feel 'somewhat fused'... but this has allowed him to have a great peg leg to use when he's walking around the yard. He's learned to 'flick the foot' to get proper placement so that he can use the leg, and his joints don't hurt him b/c he has no feeling... I only throw this out as an alternate 'end goal' if need be.
So I'm back to, maybe not just yet, but maybe in the next month, consider trying to create something for independent walking...
An air splint might be another option (with a bootie or front limb dorsiflex assist for foot position... or make something up to hold the foot in position as you 'play' with what might work.)
Cheers,
Laurie

Oops! Yes-NMES on triceps. So far nothing active motor wise at the elbow. The owners took her for a swim in their pool- supported of course, and all family members swear to seeing her attempt to use her shoulder in a dog paddle movement. She is a determined puppy girl!

So, she has quite a tight elbow- minus about 30 degrees of extension, even though I have tried to keep it at neutral to no avail. I can get her carpus to neutral extension. Was considering a dorsiflex assist splint but need to work more on the elbow extension. The end feel is quite firm.

She saw Neuro yesterday who was not optimistic at getting any elbow return, but at least encouraged more stretching and to give it another 2 months to see what comes.

I'd like to think that she is pain free and annoying sensation free due to early laser at c-spine, thoracic segments and axilla.

I am worried about the elbow ROM- and also hoping to see some triceps return soon to begin to counter that- but not too optimistic. If there is no return, at least it won't drag. Thoughts?

Will keep moving ahead! Thanks very much!

It really is a 'catch 22': If the leg is to come around to normal function & ability to weight bear, then ROM would be key; If the leg is to remain paralyzed then some contracture prevents a drag! You are likely best to aim for the middle. Continue to stretch manually... knowing that a passive periodic manual stretch will never beat a contracture, but hoping that if some function returns that one could THEN get more range because of weight bearing OR at that point a splint could be made to apply a continuous stretching force. Should there be no return, then there doesn't need to be as much focus on stretching of the biceps / brachialis, and the limb can contract more then.

Laurie

Yes- thanks for that advice on the elbow. I am doing some mobs, stretching, weight bearing with manual assistance, and the owner has been ranging her and is ramping up daily stretching. I have also been thinking "the middle way", even though the neuro vet who saw her last week (in the 6th week post accident) said to "aggressively" stretch her, though was not optimistic about much return. That makes me a little uneasy. Good news though is that I was able to get into the family's pool yesterday with Josey and she clearly is trying to advance the left front to match the dog paddling she does on the R. I think it is really all shoulder/scapular movement, essentially substitution, but owner will keep swimming with her. She is all puppy and loves to roll in the grass, rough up her towel when drying off. All good stuff! I am next trying more "fore arm weight bearing" as well to encourage shoulder, scap stability too.
Are there other NMES settings try at this stage? Thank you VERY much!!

Well, to be honest, it won't matter how 'aggressive' you are in a rehab session - you won't make gains on a contracture unless you hold the joint in position with some sort of device and/or the dog uses the limb. So don't worry about that.

Setting for e-stim... no nothing you can change there, but test the carpal flexor & extensor muscle periodically as well. (Flexors are medial & ulnar nerve; extensors are radial as well.) Might as well play around with other muscle groups to see how 'everyone else' is doing (scapular muscles, lats, biceps...) - just as a test.

The swimming sounds like a great exercise! You should see if you can get someone to take a video!

Laurie