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Updated: Jan 13, 2026
Structured Motor Rehabilitation After Selective Nerve Transfers
Published on: August 15, 2019
Implementing Donor Activation Focused Rehabilitation Approach (DAFRA) following nerve transfers for children with
Ann Marie Feretti1, Megan Gotlieb-Horowitz2, Victoria Robbins3
1Motion PT Group, Bronx, NY, USA; University of Vermont, Burlington, VT, USA.
Insights
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.
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.
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