Clinical Blind Spots: When Familiar Treatments Fall Short

Written by:

Brenda Stewart, OTR/L

Virtual Hand Therapy Fellow ‘25/’26

Occupational therapists work with a wide range of diagnoses, which means clinicians may encounter conditions that are unfamiliar or infrequently treated. In these situations, it is natural to draw from familiar treatment strategies learned through formal education, continuing education courses, or commonly used clinical techniques. However, when a condition is complex and unfamiliar, applying familiar strategies without fully considering the underlying pathology can unintentionally lead to clinical blind spots. Dalla Rosa, Chiffi, and Andreoletti (2024) note that without a structured framework for clinical reasoning, clinicians may be more likely to rely on habitual decision-making when navigating complex cases.

Over the past two years, I observed three therapists manage range of motion (ROM) in three different patients with conservatively treated brachial plexus injuries (BPI), one of the most complex and challenging conditions affecting the upper extremity. In each case, the clinicians approached treatment thoughtfully and with the patient’s best interest in mind. However, the management strategies varied significantly and did not always align with the specific needs of the diagnosis. These examples are not intended to critique individual therapists. Rather, they illustrate how easily clinical blind spots can arise in everyday practice when time is limited and the diagnosis is unfamiliar.

1. The Over Ranger

A 42-year-old male was newly admitted to a skilled nursing facility following a brachial plexus injury. Prior to admission, he had been treated in an outpatient setting where a therapy student performed aggressive range of motion exercises. The patient reported increased pain and decreased motion following the session, ultimately leaving him unable to safely return home and requiring skilled nursing placement.

In this case, the upper extremity appeared to be treated primarily as a stiff joint, without fully accounting for the underlying neural injury. Aggressive ROM in the presence of neural vulnerability

may increase traction on the brachial plexus, potentially exacerbating symptoms and impairing recovery.

2. The Under Ranger

A 38-year-old male with a brachial plexus injury was treated in an outpatient setting by a therapist highly experienced in managing SLAP tears. Out of caution, the therapist applied principles commonly used for hypermobile SLAP lesions, prioritizing stability over mobility to avoid potential tissue stress.

While this protective approach is appropriate for certain shoulder conditions, the same strategy may limit opportunities for early mobility in brachial plexus injuries. In this situation, the rehabilitation approach reflected sound reasoning based on prior experience, but the principles guiding treatment did not fully match the needs of the neural injury.

3. The Non Ranger

A 53-year-old long-term care resident with a suspected brachial plexus injury received no range of motion while awaiting MRI confirmation. Uncertainty regarding appropriate precautions led to avoidance of movement throughout the entire upper extremity. During this waiting period, the patient developed joint stiffness and contractures that may have been preventable with carefully guided mobility. This case illustrates how uncertainty surrounding unfamiliar diagnoses can sometimes lead to overly cautious treatment decisions.

A report by Rai and Raghuveer (2025) describes key components of brachial plexus injury rehabilitation, including early individualized programming, multisensory input, motor re-education, graded motor imagery, pain modulation, biofeedback, strengthening, and neuromuscular control. The authors also emphasize that maintaining joint mobility and preventing stiffness may support nerve regeneration and improve both motor and sensory outcomes.

Zapałowicz and Radek (2018) describe a predictable pattern of movement that recreates the traction mechanism responsible for many brachial plexus injuries: arm abduction combined with shoulder depression and contralateral cervical flexion. Because this position increases tension on the brachial plexus, rehabilitation strategies should aim to avoid reproducing this composite pattern during range of motion activities. Instead, mobility should be performed while minimizing neural tension. Safe mobility strategies for BPI include neural mobilization techniques, such as nerve flossing, performed in a manner that does not increase neural irritability. Composite neurodynamic positions and prolonged lengthened postures should generally be avoided.

Supportive devices such as the GivMohr sling can assist in maintaining optimal muscle length, preventing adaptive shortening, and preserving cross-bridge formation to support motor recovery. When direct neural mobilization is not tolerated, contralateral limb nerve mobilization may provide indirect benefit through system-wide neural excursion (Deisher, 2024). Brito, White, Hill, and

Thomacos (2022) note that brachial plexus injuries are highly complex and variable, and important rehabilitation strategies can easily be overlooked. Hand therapists interviewed in the study reported inconsistent training opportunities, limited structured peer support, and relatively few professional development resources specifically focused on BPI rehabilitation. These gaps can leave clinicians with fewer resources and less confidence when managing this challenging diagnosis.

Recognizing these challenges, I sought opportunities to deepen my own clinical reasoning and better understand complex upper limb conditions. One of the ways I addressed this knowledge gap was through the year-long Virtual Hand to Shoulder Fellowship, which provided structured mentorship, case-based discussion, and exposure to diverse clinical perspectives. Programs that emphasize mentorship, critical thinking, and collaborative learning may help clinicians strengthen their clinical reasoning and improve decision-making when managing complex diagnoses such as brachial plexus injuries.

Rai, A., Raghuveer, R., Gangwani, N., & Kolhe, P. D. (2025). Effects of tailored rehabilitation strategies in a conservatively managed traumatic brachial plexus injury in a 27‑year‑old male patient: A case report. Cureus, February 8, 2025.

Dalla Rosa, D., Chiffi, D., & Andreoletti, M. (2024). Philosophy and clinical reasoning in rehabilitation sciences: Bridging the gap. Global Philosophy, 34(1), Article 10

Zapałowicz, K., & Radek, A. (2018). Cadaveric analysis of traction mechanisms in brachial plexus injury.

Deisher, M. (2024). Case Study 3.3: Brachial Plexus Injury. Virtual Hand to Shoulder Fellowship, Hand to Shoulder Rehabilitation Curriculum.

Brito, S., White, J., Hill, B., & Thomacos, N. (2022). Effective long‑term management of brachial plexus injury following surgery: What is needed from hand therapists’ perspectives. Journal of Hand Therapy, 35(2), 267–274.