Implementing Donor Activation Focused Rehabilitation Approach (DAFRA) following nerve transfers for children with brachial plexus birth injury: A case series

Ann Marie Feretti ¹, Megan Gotlieb-Horowitz ², Victoria Robbins ³

⁰Motion PT Group, Bronx, NY, USA; University of Vermont, Burlington, VT, USA.

Journal of Hand Therapy : Official Journal of the American Society of Hand Therapists +

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January 7, 2026

View abstract on PubMed

Summary

A new rehabilitation protocol for brachial plexus birth injuries (BPBI) in infants and toddlers shows promising results. This play-based approach improves nerve transfer outcomes, offering a developmentally appropriate solution for pediatric patients.

Area Of Science

Pediatric Orthopedics
Pediatric Neurosurgery
Rehabilitation Medicine

Background

Nerve transfers are crucial for restoring upper limb function in infants with brachial plexus birth injuries (BPBI).
Standardized, pediatric-specific rehabilitation protocols are lacking, leading to potential failure with adult-focused approaches.
Developmentally inappropriate rehabilitation may hinder outcomes for complex nerve transfers in young children.

Purpose Of The Study

To introduce a structured, milestone-based rehabilitation protocol adapted from the Donor Activation Focused Rehabilitation Approach (DAFRA).
To evaluate functional outcomes in infants and toddlers undergoing nerve transfers for BPBI using this adapted protocol.
To report findings using a case-series design.

Main Methods

A three-phase, play-integrated rehabilitation protocol was implemented for infants and toddlers undergoing nerve transfers (SAN-SSN, MPN-AxN, Oberlin, double fascicular).
The protocol emphasized donor-recipient muscle re-education through functional activities, co-activation, and caregiver involvement.
Outcomes were assessed using the Active Movement Scale (AMS).

Main Results

Spinal accessory to suprascapular nerve (SAN-SSN) transfers resulted in 71.4% achieving full external rotation (AMS 7).
Medial pectoral to axillary nerve (MPN-AxN) transfers showed significant improvements in abduction (median AMS 5) and flexion (median AMS 6).
Double fascicular transfers for elbow flexion yielded significant gains (median AMS 6), with biceps strength improving from MRC 0 to MRC 4 (p=0.002).

Conclusions

A structured, milestone-based, play-integrated DAFRA protocol demonstrates positive outcomes for pediatric nerve transfers in BPBI.
Developmentally appropriate rehabilitation is key to reducing failure rates in these complex cases.
This approach supports the broader adoption of specialized pediatric rehabilitation protocols.

Keywords:

Brachial plexus neuropathies Infant Nerve transfer Occupational therapy Rehabilitation Treatment outcome