Revisiting Obstetric Brachial Plexus Injuries Through a Central Nervous System Lens: Toward Integrated Diagnostic and Therapeutic Frameworks.

Obstetric brachial plexus injury (OBPI) has long been considered primarily a peripheral nerve disorder. However, recent studies increasingly suggest central nervous system (CNS) involvement, which may play an important role in shaping clinical outcomes and guiding treatment decisions. This review examines the neurophysiological and neuroimaging evidence pointing to CNS alterations in individuals with OBPI, including impaired motor programming, developmental apraxia, altered interhemispheric dynamics, and reorganization of sensorimotor cortical areas. Techniques such as functional magnetic resonance imaging, navigated transcranial magnetic stimulation, and near-infrared spectroscopy have helped reveal these central adaptations. Additionally, the review highlights the role of motor imagery, reaction time, and hand laterality judgment as potential indirect clinical markers of CNS involvement. Beyond these indirect approaches, no clinically applicable scale for assessing central involvement in OBPI has yet been established. Despite advances in rehabilitation strategies, most conventional approaches continue to focus on the affected limb, often overlooking the broader neural mechanisms. Considering the brain's potential for plasticity, particularly in children, CNS-focused interventions such as sensory training, virtual reality therapies, motor imagery, noninvasive brain stimulation, constraint-induced movement therapy, and environmental enrichment could support wider functional recovery. Although some of these approaches are part of conventional rehabilitation practice, their relevance to CNS involvement in OBPI has not yet been clearly established. Further research is needed to identify and evaluate assessment and treatment approaches that take CNS involvement into account in OBPI.