Brachial plexus birth injuries: a multi-speciality approach. Commentary and opinions.

The management of brachial plexus birth injuries (BPBI) remains controversial and ever evolving. In this article, studies are examined to provide further insight into the ongoing controversies and debates surrounding BPBI. The articles are diverse and examine the topics of aetiology, demographics, reliability versus accuracy of measurements and surgical management. The management of BPBI may differ depending on resources. Outcome measures may also vary depending on geography. Future research should focus on developing consensus-validated measures and reproducible surgical techniques. These can then guide further population-based research and provide guidelines to minimize the incidence of BPBI.

Rehabilitation protocols in neonates undergoing primary nerve surgery for upper brachial plexus palsy: A scoping review.

INTRODUCTION: Surgical management is recommended in patients with severe neonatal brachial plexus palsy (NBPP) within the first 6 months of age to regain best possible function. Rehabilitation post-surgery remains relatively unexplored. This is a scoping review that explores, which rehabilitation modalities exist and how they vary for different microsurgical approaches in NBPP. MATERIALS AND METHODS: A systematic search was conducted to include articles about upper trunk obstetric brachial plexus nerve microsurgery in pediatric patients that made mention of rehabilitation protocols. The aims of rehabilitation modalities varied and were grouped: "passive" movement to prevent joint contracture or stiffness, "active" or task-oriented movement to improve motor function, or "providing initial motor recovery". Surgical approach was described as either exploration of the brachial plexus (EBP) or nerve transfer without root exploration (NTwoRE). Technique was categorized into transfers and non-transfers. RESULTS: Thirty-six full-text articles were included. Initiation of rehabilitation was 22.26 days post-surgery. Twenty-eight studies were EBP, and six were NTwoRE. Of studies classifiable by aims, nine were "passive", nine were "active", and five were "providing initial motor recovery". Only 27.7% of EBP studies mentioned active therapy, while 75.0% of NTwoRE studies mentioned active therapy. The average age of patients in the EBP procedure category was 7.70 months, and NTwoRE was 17.76 months. Within transfers, the spinal accessory to suprascapular group was more likely to describe an active shoulder exercise therapy, whereas contralateral C7 group was more likely to describe "initial motor recovery", especially through the use of electrostimulation. All articles on electrostimulation recommended 15-20-minute daily treatment. CONCLUSION: Information on rehabilitation is limited post-nerve surgery in NBPP. However, when mentioned, the aims of these therapies vary with respect to surgical approach and technique. The type of therapy to employ may be a multifaceted decision, involving factors such as patient age, initial deformity, and goals of the care team.

Brachial plexus birth injury: advances and controversies.

While there is considerable spontaneous recovery in most cases of brachial plexus birth injury, many children are left with significant problems that may lead to lifelong functional limitations, loss of work and social isolation. Detailed treatment with the right strategy can provide very valuable improvement in function. Over the past few years, the clinical approach to brachial plexus birth palsy has entered a new era in both diagnostic and surgical treatment methods. This article reviews four areas of management, the role of imaging in defining the severity of the injury, the optimal timing of for nerve exploration and reconstruction in appropriate cases, the advantages and potential complications of nerve transfers, and the role of physiotherapy. Available evidence is considered. Although it is difficult to make clear and precise inferences on a subject where there are many variables and considerable uncertainties, some currently accepted views will be summarized.Level of evidence: V.

Hand function outcomes following surgical treatment of complete neonatal brachial plexus palsy.

PURPOSE: Although re-innervation of the hand is considered a priority in the treatment of infants with complete brachial plexus injury, there is currently a paucity of publications investigating hand function outcomes following primary nerve reconstruction in infants with neonatal brachial plexus palsy (NBPP). This study therefore aimed to evaluate hand function outcomes in a series of patients with complete NBPP. METHODS: This retrospective case series included all patients who underwent primary nerve surgery for complete neonatal brachial plexus palsy over an 8-year period. Outcomes were assessed using the Raimond Hand Scale. Classification of grade 3 or higher indicates a functional hand (assistance in bimanual activity). RESULTS: Nineteen patients with a complete NBPP underwent primary nerve reconstruction at a mean age of 3.7 months. Periodic clinical evaluations were performed until at least 4 years of age. According to the Raimondi hand scale, one patient did not recover (grade 0), three patients attained grade 1, four grade 2, ten grade 3, and in one grade 4. Overall hand functional recovery was achieved in 57.8% (11/19) of patients. CONCLUSION: Sufficient recovery of hand function to perform bimanual activity tasks in patients with complete NBPP lesions is possible and should be a priority in the surgical treatment of these infants.

Subscapularis impairment on magnetic resonance imaging is correlated with functional limitations in neonatal brachial plexus palsy.

PURPOSE: The relationship between functional shoulder deficits in children with neonatal brachial plexus palsy (NBPP) and magnetic resonance imaging (MRI) shoulder abnormalities was evaluated. METHODS: Shoulder function was assessed in 16 children (mean age: 5.8 years; range: 3-12 years) with NBPP based on shoulder rotator muscle strength, as measured using an isokinetic dynamometer and the modified Mallet score. The thickness and fatty infiltration of the subscapularis and infraspinatus muscles, and the morphology of the glenoid on MRI, were also determined. RESULTS: The highest subscapularis fatty infiltration subgroup of NBPP patients promoted the highest alteration muscle thickness and modified Mallet score. CONCLUSIONS: In NBPP children, subscapularis impairments play a major role in the functional limitations. This study of pediatric NBPP patients highlighted the value of adding an examination of the muscles to routine MRI assessment of bone parameters in the shoulders of NBPP children. TRIAL REGISTRATION: NCT03440658.

Recovery of Shoulder, Elbow, and Forearm Movement After Nerve Reconstruction for Neonatal Brachial Plexus Palsy.

BACKGROUND AND OBJECTIVES: There is a relative dearth of published data with respect to recovery of upper extremity movement after nerve reconstruction for neonatal brachial plexus palsy (NBPP). This study aimed to demonstrate long-term recovery of active range of motion (AROM) at the shoulder, elbow, and forearm after nerve reconstruction for NBPP and to compare that with patients managed nonoperatively. METHODS: We interrogated a prospectively collected database of all patients evaluated for NBPP at a single institution from 2005 to 2020. AROM measurements for shoulder, elbow, and forearm movements were collected at every visit up to 5 years of follow-up and normalized between 0 and 1. We used generalized estimated equations to predict AROM for each movement within local age windows over 5 years and compared the operative and nonoperative cohorts at each age interval. RESULTS: In total, >13 000 collected datapoints representing 425 conservatively and 99 operatively managed children were included for analysis. At 5 years, absolute recovery of AROM after nerve reconstruction was ∼50% for shoulder abduction and forward flexion, ∼65% for shoulder external rotation, and ∼75% for elbow flexion and forearm supination, with ∼20% loss of elbow extension AROM. Despite more limited AROM on presentation for the operative cohort, at 5 years, there was no significant difference between the groups in AROM for shoulder external rotation, elbow extension, or forearm supination, and, in Narakas grade 1-2 injury, shoulder abduction and forward flexion. CONCLUSION: We demonstrate recovery of upper extremity AROM after nerve surgery for NBPP. Despite more severe presenting injury, operative patients had similar recovery of AROM when compared with nonoperative patients for shoulder external rotation, elbow extension, forearm supination, and, for Narakas grade 1-2 injury, shoulder abduction and forward flexion.

Brain plasticity in neonatal brachial plexus palsies: quantification and comparison with adults' brachial plexus injuries.

PURPOSE: To compare two populations of brachial plexus palsies, one neonatal (NBPP) and the other traumatic (NNBPP) who underwent different nerve transfers, using the plasticity grading scale (PGS) for detecting differences in brain plasticity between both groups. METHODS: To be included, all patients had to have undergone a nerve transfer as the unique procedure to recover one lost function. The primary outcome was the PGS score. We also assessed patient compliance to rehabilitation using the rehabilitation quality scale (RQS). Statistical analysis of all variables was performed. A p ≤ 0.050 set as criterion for statistical significance. RESULTS: A total of 153 NNBPP patients and 35 NBPP babies (with 38 nerve transfers) met the inclusion criteria. The mean age at surgery of the NBPP group was 9 months (SD 5.42, range 4 to 23 months). The mean age of NNBPP patients was 22 years (SD 12 years, range 3 to 69). They were operated around sixth months after the trauma. All transfers performed in NBPP patients had a maximum PGS score of 4. This was not the case for the NNBPP population that reached a PGS score of 4 in approximately 20% of the cases. This difference was statistically significant (p < 0.001). The RQS was not significantly different between groups. CONCLUSION: We found that babies with NBPP have a significantly greater capacity for plastic rewiring than adults with NNBPP. The brain in the very young patient can process the changes induced by the peripheral nerve transfer better than in adults.

Brain plasticity and age after restoring elbow flexion with distal nerve transfers in neonatal brachial plexus palsy and nonneonatal traumatic brachial plexus injury using the plasticity grading scale.

OBJECTIVE: Ulnar and/or median nerve fascicle to musculocutaneous nerve (MCN) transfers are used to restore elbow flexion following severe neonatal and nonneonatal brachial plexus injuries (BPIs). Restoring volitional control requires plastic changes in the brain. To date, whether the potential for plasticity is influenced by a patient's age remains unknown. METHODS: Patients who had presented with a traumatic upper (C5-6 or C5-7) BPI were divided into two groups: neonatal brachial plexus palsies (NBPPs) and nonneonatal traumatic BPIs (NNBPIs). Both groups underwent ulnar or median nerve transfers to the MCN for elbow flexion restoration between January 2002 and July 2020. Only those who attained a British Medical Research Council strength rating of 4 were reviewed. The primary comparison between the two groups was the plasticity grading scale (PGS) score to determine the level of independence of elbow flexion (target) from forearm motor muscle movement (donors). The authors also assessed patient compliance with rehabilitation using a 4-point Rehabilitation Quality Scale. Bivariable and multivariable analyses were used to identify intergroup differences. RESULTS: In total, 66 patients were analyzed: 22 with NBPP (mean age at surgery 10 months) and 44 with NNBPI (age range at surgery 3-67 years, mean 30.2 years; mean time to surgery 7 months, p < 0.001). All NBPP patients obtained a PGS grade of 4 at the final follow-up versus just 47.7% of NNBPI patients (mean 3.27, p < 0.001). On ordinal regression analysis, after nature of the injury was excluded because of excessive collinearity with age, age was the only significant predictor of plasticity (ß = -0.063, p = 0.003). Median rehabilitation compliance scores were not statistically different between the two groups. CONCLUSIONS: The extent of plastic changes that occur for patients to regain volitional control over elbow flexion after upper arm distal nerve transfers following BPI is influenced by patient age, with complete plastic rewiring more likely in younger patients and virtually ubiquitous in infants. Older patients should be informed that elbow flexion after an ulnar or median nerve fascicle transfer to the MCN might require simultaneous wrist flexion.

Similar Cognitive Skill Impairment in Children with Upper Limb Motor Disorders Due to Arthrogryposis Multiplex Congenita and Obstetrical Brachial Plexus Palsy.

Arthrogryposis multiplex congenita (AMC) and obstetrical brachial plexus palsy (OBPP) are motor disorders with similar symptoms (contractures and the disturbance of upper limb function). Both conditions present as flaccid paresis but differ from each other in the pathogenesis: AMC is a congenital condition, while OBPP results from trauma during childbirth. Despite this difference, these diseases are identical in terms of their manifestations and treatment programmes. We compared the cognitive skills of children with AMC and OBPP diagnoses with those of healthy children; we also compared the motor skills of impaired children with those of healthy ones. The patients in both groups significantly differed from the healthy children with regard to psychological parameters, such as 'visual memory capacity' and 'thinking'. Moreover, the two groups with children with AMC and OBPP significantly differed from each other in motor skill parameters, such as 'delayed motor development', 'general motor development', and the 'level of paresis'. Upper limb motor function in the OBPP children was less impaired compared to that of the AMC children. However, we did not find any significant differences in cognitive deficits between the AMC children and the OBPP children. This may indicate that motor impairment is more significant than the underlying cause for the development of cognitive impairment; however, the factors causing this phenomenon require further study (e.g., social environment, treatment, and rehabilitation programme).

Comorbidities in Infants and Children with Neonatal Brachial Plexus Palsy: A Scoping Review to Inform Multisystem Screening.

AIMS: The scoping review was undertaken to explore comorbidities in infants and children with neonatal brachial plexus palsy (NBPP). The purpose of the review was to inform physical and occupational therapy screening of multiple body systems during the examination of children with NBPP. METHODS: EBSCO Discovery and EMBASE electronic databases were searched for reports published between January 1996 and September 2021 describing comorbidities in children with NBPP between birth and 18 years. Key data pertaining to comorbidity prevalence, risk factors, clinical features, and associated outcomes were extracted and charted by one researcher and confirmed by a second researcher. RESULTS: Thirty-six articles were included in the scoping review. Fourteen comorbidities were identified across the musculoskeletal, neurological, cardiopulmonary, and integumentary systems and the communication domain. The most prevalent comorbidities were clavicle fractures, plagiocephaly, torticollis, high body mass index, and language delays. The least prevalent comorbidity was facial nerve palsy. CONCLUSIONS: Physical and occupational therapists can use knowledge of comorbidities in infants and children with NBPP for multisystem screening during the examination. A thorough history can identify risk factors for comorbidities. Detection of comorbidities during screening allows for timely specialty referrals to optimize care.

Tendon Transfers to Restore Shoulder Function for Obstetrical Brachial Plexus Palsy: A Systematic Review of the Literature.

BACKGROUND: Obstetrical brachial plexus palsy (OBPP) is a relatively common stretch injury of the brachial plexus sustained during delivery. Tendon transfers are commonly performed to improve shoulder function among patients with OBPP. Although several techniques for the surgical management of OBPP exist, it is unclear whether tendon transfers to the rotator cuff vs. posterior humerus yield different outcomes. METHODS: A systematic search in PubMed, Web of Science, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and Google Scholar up to January 1, 2021, was performed. Relevant publications were classified by surgical technique of tendon transfers to the rotator cuff or posterior humerus. The standard mean difference (SMD) and 95% confidence intervals were calculated to compare preoperative and postoperative aggregate Mallet scores as well as abduction and external rotation scores using the Mallet scale. A p value of <0.01 was considered significant. RESULTS: Data from 26 studies and 951 patients (46.2% male patients) with a mean age of 68.9 ± 29.3 months were included. Eight hundred three patients underwent tendon transfer to the rotator cuff and 148 to the posterior humerus. The average postoperative follow-up period was 45.2 ± 21.7 months. The pooled cohort had an overall improvement in postoperative aggregate Mallet scores (SMD = 5.53, p < 0.001), abduction scores (SMD = 1.79, p < 0.001), and external rotation scores (SMD = 1.99, p < 0.001). Tendon transfer to the rotator cuff had a greater postoperative improvement in abduction (SMD = 1.90, p < 0.001) than transfer to the posterior humerus (SMD = 1.32, p < 0.001) while both techniques yielded similar improvements in external rotation (rotator cuff SMD = 2.01, p < 0.001, posterior humerus SMD = 1.98, p < 0.001). CONCLUSION: This is the first systematic review comparing outcomes for tendon transfers to the rotator cuff vs. the posterior humerus for improving shoulder function in patients with OBPP. Overall, tendon transfers are an effective treatment for improving shoulder function. Transfer of the latissimus dorsi and teres major to the rotator cuff compared with transfer to the posterior humerus results in greater improvement in abduction while both techniques have similar results in improving external rotation. LEVEL OF EVIDENCE: Level I Systematic review of Level I and Level II studies.

Is mirror therapy combined with a routine physiotherapy protocol effective for children with obstetrical upper brachial plexus palsy?

STUDY DESIGN: Randomized controlled study. INTRODUCTION: Mirror therapy is a rehabilitation strategy based on the repeated use of the mirror illusion and also one of the treatment choice of brachial plexus injuries. PURPOSE: We aimed to determine the effects of mirror therapy combined with a routine rehabilitation program on upper limb motor function in children with obstetric brachial plexus injury. METHODS: Twenty children with obstetric brachial palsy were included in this study. They were randomly allocated to either control (n = 10) or mirror therapy (n = 10) group. The following clinical tools were used to assess the upper extremity function: Active Movement Scale (AMS), Modified Mallet Scale (MMS), Hand Grip Strength (HGS) Test, Finger Grip Strength (FGSM) Test, Box and Block Test (BBT), Nine Hole Peg Test (9-HPT), and goniometric measurement. Both groups received the same routine physiotherapy program for 8 weeks. The study group underwent mirror therapy in addition to the rehabilitation program. RESULTS: The mean age of the study population was 11.35 ± 4.12 years. There was no change in the goniometric values, AMS and MMS scores after the treatment in both groups (p > 0.05), except for the improvement of the wrist extension in the study group (p < 0.05). There was an increase in both HGS and FGS scores in the study group. Only FGS scores improved in the control group after the intervention (p < 0.05). 9-HPT and BBT scores improved in both groups (p < 0.05). All other parameters tested were comparable between the two groups after the treatment. CONCLUSIONS: The results of this study did not show any additional benefits of mirror therapy combined with a rehabilitation protocol compared to routine physiotherapy treatment, but was not adequately powered to do so.

Tactile Perception of the Hand in Children With an Upper Neonatal Brachial Plexus Palsy.

OBJECTIVE: To investigate factors that cause impairment of hand function in children with an upper Neonatal Brachial Plexus Palsy (NBPP), we performed an in-depth analysis of tactile hand sensibility, especially the ability to correctly localize a sensory stimulus on their fingers. DESIGN: A cross-sectional investigation of children with NBPP, compared with healthy controls. The thickest Semmes-Weinstein (SW) monofilament was pressed on the radial or ulnar part of each fingertip (10 regions), while a screen prevented seeing the hand. SETTING: Tertiary referral center for nerve lesions in an academic hospital in The Netherlands. The control group was recruited at their school. PARTICIPANTS: Forty-one children with NBPP (mean age 10.0 y) and 25 controls (mean age 9.5 y; N=41). INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: Correct localization of the applied stimuli was evaluated, per region, per finger, and per dermatome with a test score. The affected side of the NBPP group was compared with the non-dominant hand of the controls. RESULTS: The ability to localize stimuli on the tips of the fingers in children with an upper NBPP was significantly diminished in all fingers, except for the little finger, as compared with healthy controls. Mean localization scores were 6.6 (thumb) and 6.3 (index finger) in the NBPP group and 7.6 in both fingers for controls (maximum score possible is 8.0). Localization scores were significant lower in regions attributed to dermatomes C6 (P<.001) and C7 (P=.001), but not to C8 (P=.115). CONCLUSION: Children with an upper NBPP showed a diminished and incorrect ability to localize sensory stimuli to their fingers. This finding is likely 1 of the factors underlying the impairment of hand function and should be addressed with sensory focused therapy.

Elbow flexion contractures in neonatal brachial plexus palsy: A one-year comparison of dynamic orthosis and serial casting.

OBJECTIVE: Elbow flexion contractures are common complications of neonatal brachial plexus palsy, but evidence on how to treat these contractures is weak. This study compared the treatment of elbow flexion contractures using a dynamic orthosis or serial circular casting. METHODS: A randomized controlled trial was conducted with one-year follow-up. Children with an elbow flexion contracture of ≥30° were treated with either a night-worn dynamic orthosis for one year or serial casting for four weeks followed by night splinting. For pragmatic reasons, some participants were included in an open part of this study, this group was also analyzed separately. Degree of contracture and goal attainment scaling was evaluated at baseline and after 8, 20 and 54 weeks. RESULTS: 55 patients were analyzed in this trial, 32 of whom were randomized to treatment. At one-year follow-up of the randomized group, both dynamic splinting (median -8.5°, interquartile range [IQR] -13.5, -5) and serial casting (median -11.0°, IQR -16, -5) resulted in significant reduction of contracture (P < 0.001). The reduction was significantly greater with serial casting in the first 20 weeks, but not at one-year follow-up (P = 0.683). In the entire cohort, the individual functional goals had been reached in 24 out of 32 cases (80%) of dynamic splinting and 18 out of 23 cases (82%) of serial casting, respectively. CONCLUSION: The dynamic night orthosis is comparable to serial casting for treating elbow flexion contractures in children with brachial plexus birth injury. We recommend selecting one of these treatment modalities in close consultation with parents and patients.

Quantifying real-world upper limb activity via patient-initiated spontaneous movement in neonatal brachial plexus palsy.

BACKGROUND: Neonatal brachial plexus palsy (NBPP) results in muscle weakness and impaired somatosensory function of the arm. Current functional assessment is primarily based on clinician-elicited measurements including muscle strength and range of motion. To what extent these measures are representative of real-world arm movement is unclear. OBJECTIVE: To determine the feasibility of using body-worn accelerometers to remotely assess arm movements in children with NBPP. DESIGN: Prospective criterion validity study of accelerometry versus clinician assessment. SETTING: Academic medical center. PARTICIPANTS: Nine adolescents with NBPP and nine age- and gender-matched control adolescents participated in the study. All were enrolled in school and participated in community activities. INTERVENTIONS: Not applicable. METHODS: Standard clinician-elicited measurements were collected. For assessing spontaneous arm movements, participants wore activity monitors during all waking hours for 7 days. Results were expressed as ratios of affected to unaffected arm motion for duration and magnitude and correlated with traditional clinic-based assessments. Spearman correlations were used to determine relationships between accelerometry results and traditional assessments. A p value <.05 was considered statistically significant. MAIN OUTCOME MEASUREMENTS: Accelerometry measurements of arm motion and traditional clinical assessments. RESULTS: Compared to control ratios, duration of arm movement and magnitude ratios were reduced in the NBPP group, particularly for arm magnitude due to reduced affected arm movement and an increase in unaffected arm movement. Ratios were highly correlated with shoulder function and, to a lesser extent, with elbow function. CONCLUSION: Real-world arm use is an appropriate outcome measure that reflects functional recovery. This study demonstrates the feasibility of wearable technology to quantify duration and intensity of spontaneous arm movement in children with NBPP. Accelerometry also allows for the association between traditional clinician-elicited assessment measures and spontaneous arm movements, demonstrating the importance of the shoulder as a focus of treatment in NBPP.

Clinical and psychosocial outcomes following correction of supination deformity in obstetrical brachial plexus palsy patients: A retrospective study.

BACKGROUND: Forearm supination contracture is the mostAQ common deformity of the forearm following obstetric brachial plexus palsy (OBPP). Supination deformities in OBPP may be corrected by performing forearm osteotomy; however, the high recurrence rate limits patient satisfaction. Apart from the cosmetic impairment of this deformity, there are no previous reports on the clinical and psychosocial outcomes of forearm osteotomy in patients with supination deformities secondary to OBPP. Therefore, our study aimed to assess the clinical, functional, and psychosocial outcomes following forearm pronation osteotomy in OBPP patients with supination deformity. METHODS: This retrospective study was conducted after a chart review of all OBPP sequelae with supination forearm deformity in patients who underwent forearm pronating osteotomy from 2006 to 2018. Data relating to OBPP were gathered, and functional and psychosocial outcomes were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire through interviews RESULTS: This study included 60 patients with a mean age of 8.7 years at the time of surgery. A total of 46 patients had lesions involving C5-T1 (76.7%). The mean preoperative supination deformity position was 68.5°, the mean amount of correction was 98.9°, and the mean forearm position was 30.5°, postoperatively. In the DASH assessment scale used postoperatively, 24 patients (42.9%) reported no restrictions on their daily activities, 25 patients (44.6%) believed that their social activities were unaffected, and 20 patients (35.7%) strongly disagreed with feeling less capable or less confident due to arm, shoulder, or hand problems. The factors significantly affecting position at the final follow-up were the amount of correction (p = 0.011), postoperative position (p = 0.005), and degree of pronation achieved (p = 0.02). The amount of correction significantly affected both self-confidence (p = 0.049) and activities of daily living (p = 0.033). CONCLUSION: In conclusion, our study showed that the position at the final follow-up, the degree of pronation achieved intraoperatively, and the postoperative position significantly affected the position at follow-up and the outcome assessment. The amount of intraoperative correction was significantly associated with higher self-confidence and normal activities of daily living.

Neonatal brachial plexus palsy - early diagnosis and treatment.

Background and purpose: The incidence of brachial plexus palsy (BPP) has decreased recently, but the indivi-d-ual's quality of life is endangered. To provide better chan-ces to BPP neonates and infants, the Department of Developmental Neurology worked out, introduced, and applied a complex early therapy, including nerve point stimulation. Methods: After diagnosing the severity of BPP, early intensive and complex therapy should be started. Appro-x-imately after a week or ten days following birth, the slightest form (neurapraxia) normalizes without any intervention, and signs of recovery can be detected around this period. The therapy includes the unipolar nerve point electro-stimulation and the regular application of those elemen-tary sensorimotor patterns, which activate both extremities simultaneously. Results: With the guideline worked out and applied in the Department of Developmental Neurology, full recovery can be achieved in 50% of the patients, and even in the most severe cases (nerve root lesion), functional upper limb usage can be detected with typically developing body-scheme. Conclusion: Immediately starting complex treatment based on early diagnosis alters the outcome of BPP, providing recovery in the majority of cases and enhancing the everyday arm function of those who only partially benefit from the early treatment.

Validation and Cultural Adaptation of the Serbian Version of the Pediatric Outcome Data Collection Instrument (PODCI) in Children with Obstetrical Brachial Plexus Lesion.

Background and objectives: Pediatric Outcome Data Collection Instrument (PODCI) is among the most described scales developed to evaluate the physical status of children and adolescents with various musculoskeletal disorders. We aimed to translate PODCI from English to Serbian, culturally adopt items and domains, evaluate the temporal stability, internal consistency and the test−retest reliability of PODCISR in children with obstetrical brachial plexus lesion (OBPL), and finally, to test the construct validity of PODCISR against muscular manual test (MMT) Materials and Methods: The study included 48 eligible participants aged between 2 and 10 years with OBPL. The MMT was used to test the construct validity. Results: There were no significant differences (p > 0.05) between test and retest for all PODCISR domains. Correlations for all tested domains with MMT were statistically significant except for biceps muscle and domains II and IV. Cronbach's alpha value of the Global Functioning Scale was good and equaled 0.838 for test and 0.832 for retest session. Cronbach's α was more than 0.600 for all PODCISR domains except for Domain II and for Domain IV. The observed Test−Retest ICC for all PODCISR domains scores ranged from 0.899 to 0.996. Conclusion: The Serbian version of PODCI (PODCISR) was successfully translated and transculturally adopted. It has satisfactory temporal stability, construct validity and test−retest reliability as well as relevant internal consistency.

Self-biting behavior in patients with neonatal brachial plexus palsy.

PURPOSE: Self-biting behavior in patients with neonatal brachial plexus palsy (NBPP) has been associated with finger amputation. Our objective is to describe the incidence of this complication, risk factors, and clinical management. METHODS: We retrospectively analyzed 612 patients with NBPP. There were 303 males and 309 females. 51.8% of patients had C5-C6 lesions, 28.9% had C5-C7, 18.9% had C5-T1, and 0.3 had C7-T1 involvement. RESULTS: We identified 15 patients with self-biting behavior (2.5%). Ten patients had C5-T1 lesions, and five had C5-C7 lesions. Eight patents were submitted to brachial plexus surgery and seven were not. This behavior appeared between 8 and 46 months of life (mean 23.5), and it was always temporary. There was no difference between operated and non-operated patients (p > 0.05), and no correlation between age at surgery and age of appearance of self-biting behavior (p > 0.05). Physical restriction was effective in treating this complication and we had no case of finger amputation. CONCLUSION: Self-biting behavior is a rare complication of NBPP, and it is usually associated with severe motor involvement. The behavior duration is limited to a few months. This condition can be effectively treated with physical restriction to prevent hand biting.