Journal of hand therapy : official journal of the American Society of Hand Therapists · 2026
Implementing Donor Activation Focused Rehabilitation Approach (DAFRA) following nerve transfers for children with brachial plexus birth injury: A case series.
СтатьяНазвание и аннотация: Перевод в очереди
Обработка статьи · этапы, ошибки и управление
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Feretti Ann Marie, Gotlieb-Horowitz Megan, Robbins Victoria, Ferrante Victoria, Khabyeh-Hasbani Nathan, DeRosa Tara, Koehler Steven M
Аннотация
BACKGROUND: Nerve transfers are increasingly used to restore upper limb function in infants and toddlers with brachial plexus birth injuries (BPBI). However, standardized, pediatric-specific rehabilitation protocols remain lacking. Adult-focused approaches are often developmentally inappropriate, and the absence of tailored rehabilitation may contribute to high failure rates, particularly for complex transfers.
PURPOSE: To present a structured, milestone-based rehabilitation protocol adapted from the Donor Activation Focused Rehabilitation Approach (DAFRA) for infants and toddlers undergoing nerve transfers for BPBI and to report functional outcomes using a case-series design.
STUDY DESIGN: Therapeutic, case series METHODS: Following IRB approval, infants and toddlers undergoing nerve transfers for BPBI at a single institution were enrolled. Procedures included spinal accessory nerve to suprascapular nerve (SAN-SSN), medial pectoral to axillary nerve (MPN-AxN), ulnar nerve fascicle to musculocutaneous branch (Oberlin), and double fascicular nerve transfers. All pati three-phase rehabilitation protocol was implemented, emphasizing donor-recipient muscle re-education through play-based functional activities, co-activation, and caregiver participation. Outcomes were assessed using the Active Movement Scale (AMS).
RESULTS: Fourteen patients underwent SAN-SSN transfer at a mean age of 7.0 months; 71.4% achieved full external rotation against gravity (AMS 7). Twenty-one underwent MPN-AxN transfer at a mean age of 8.9 months, demonstrating significant improvements in abduction (median AMS 5, IQR 3-6) and flexion (median AMS 6, IQR 5-6) (both p < 0.001). Thirteen patients underwent double fascicular nerve transfers for elbow flexion at a mean age of 10.1 months, with significant gains in elbow flexion (median AMS 6, IQR 6-7) and forearm supination (median AMS 5, IQR 3-7) (both p = 0.002). Biceps improved from median MRC 0 (IQR 0-1) preoperatively to MRC 4 (IQR 3-5) postoperatively (p = 0.002). Meaningful recovery occured in 100% for elbow flexion 62% for supination, and 70% for biceps strength.
CONCLUSIONS: A structured, milestone-based, play-integrated DAFRA protocol yields promising outcomes in infants and toddlers undergoing nerve transfers for BPBI. Developmentally appropriate rehabilitation may reduce failure rates and supports broader adoption of pediatric-specific protocols.
PURPOSE: To present a structured, milestone-based rehabilitation protocol adapted from the Donor Activation Focused Rehabilitation Approach (DAFRA) for infants and toddlers undergoing nerve transfers for BPBI and to report functional outcomes using a case-series design.
STUDY DESIGN: Therapeutic, case series METHODS: Following IRB approval, infants and toddlers undergoing nerve transfers for BPBI at a single institution were enrolled. Procedures included spinal accessory nerve to suprascapular nerve (SAN-SSN), medial pectoral to axillary nerve (MPN-AxN), ulnar nerve fascicle to musculocutaneous branch (Oberlin), and double fascicular nerve transfers. All pati three-phase rehabilitation protocol was implemented, emphasizing donor-recipient muscle re-education through play-based functional activities, co-activation, and caregiver participation. Outcomes were assessed using the Active Movement Scale (AMS).
RESULTS: Fourteen patients underwent SAN-SSN transfer at a mean age of 7.0 months; 71.4% achieved full external rotation against gravity (AMS 7). Twenty-one underwent MPN-AxN transfer at a mean age of 8.9 months, demonstrating significant improvements in abduction (median AMS 5, IQR 3-6) and flexion (median AMS 6, IQR 5-6) (both p < 0.001). Thirteen patients underwent double fascicular nerve transfers for elbow flexion at a mean age of 10.1 months, with significant gains in elbow flexion (median AMS 6, IQR 6-7) and forearm supination (median AMS 5, IQR 3-7) (both p = 0.002). Biceps improved from median MRC 0 (IQR 0-1) preoperatively to MRC 4 (IQR 3-5) postoperatively (p = 0.002). Meaningful recovery occured in 100% for elbow flexion 62% for supination, and 70% for biceps strength.
CONCLUSIONS: A structured, milestone-based, play-integrated DAFRA protocol yields promising outcomes in infants and toddlers undergoing nerve transfers for BPBI. Developmentally appropriate rehabilitation may reduce failure rates and supports broader adoption of pediatric-specific protocols.