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.

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.

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.

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.

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.

Five oriented tasks in manual skills of a baby child with obstetric brachial plexus palsy / Cinco tarefas direcionadas nas habilidades manuais de uma criança com paralisia braquial obstétrica

Brachial plexus (BP) injury during labor is called obstetric brachial palsy (OBP). It is an abnormality that occurs in the upper extremity of the body due to excessive stretching of the neural roots of the BP. Every motor skill that the child with OPB acquires will be hampered by the deficiency in the movement of an upper limb (MS), impacting his motor experimentation. To modify their motor behavior, task-directed therapy can contribute to the function of the affected upper limb, because it is characterized by a protocol of functional exercises, which is still scarce in researches aimed at this morbidity. The objective of the study was to evaluate the effect of a motor intervention by means of five directed tasks on the manual skills of the upper limb of a child with OBP, as well as on his gross motor function. The child in the study was 17 months old, with left OBP, with weakness of shoulder abduction, external rotation, elbow flexion and wrist drop. He underwent 24 physiotherapy sessions with directed tasks for 45 minutes, three times a week. The Manual Ability Classification System (MACS) was used to classify the degree of severity of the MSE. The Gross Motor Function Measure (GMFM-66) quantitatively measured motor and static aspects and the Gross Motor Function Classification System (GMFCS) was used to determine which level best represented the abilities and limitations in the child's gross motor function. The targeted tasks were based on the model of the Induced Constraint Therapy (ICT) protocol, being: find the surprise; orange spoon; hair elastic fitting; fishing for bottle caps; stacking blocks. In the post-intervention assessments, the MACS showed improvement in the tasks of finding the surprise, orange spoon, and fishing for lids, but remained the same in the level of the activities of fitting the rubber bands and stacking the blocks. The GMFM-66 obtained an increase in the final score and the GMFCS remained at the level I. The GMFM-66 showed a 4.99% improvement at the end of the intervention. The activities finding the surprise, picking oranges, and fishing for bottle caps showed an improvement in the MACS level classification compared to the initial assessment. The findings show better muscle recruitment, with refinement in elbow flexion movements, forearm supination and external rotation (ER) of the shoulder (AU)

A lesão do plexo braquial (PB) durante o parto é denominada paralisia braquial obstétrica (PBO). É uma anormalidade que ocorre na extremidade superior do corpo, em consequência de um estiramento excessivo das raízes neurais do PB. Toda habilidade motora que a criança com PBO adquirir será dificultada pela deficiência na movimentação de um membro superior (MS), repercutindo em suas experimentações motoras. Para modificar seu comportamento motor, a terapia por tarefas direcionadas pode contribuir na função do MS afetado, pois a mesma caracteriza-se com um protocolo de exercícios funcionais, que ainda há escassez em pesquisas voltados a esta morbidade. O objetivo do estudo foi avaliar o efeito de uma intervenção motora através de cinco tarefas direcionadas sobre as habilidades manuais do membro superior de uma criança com PBO, bem como sua função motora grossa. A criança do estudo tinha 17 meses, com PBO à esquerda, com fraqueza de abdução de ombro, rotação externa, flexão de cotovelo e queda do punho. Realizou 24 sessões de fisioterapia com tarefas direcionadas por 45 minutos, três vezes por semana. Para classificar o grau de severidade do MSE, foi utilizado o Manual Ability Classification System (MACS). A Medida da Função Motora Grossa (GMFM-66) mediu quantitativamente aspectos motores e estáticos e o Sistema de Classificação da Função Motora Grossa (GMFCS) foi utilizado para determinar qual nível melhor representou as habilidades e limitações na função motora grossa da criança. As tarefas direcionadas foram baseadas no modelo do protocolo de terapia por contensão induzida (TCI), sendo: achar a surpresa; colher laranja; encaixar elástico de cabelo; pescaria de tampinhas; empilhar blocos. Nas avaliações pós-intervenção, o MACS demonstrou melhora no nível das tarefas de achar a surpresa, colher laranja e pescaria de tampinhas, mas manteve-se igual no nível das atividades de encaixar os elásticos e empilhar os blocos. O GMFM-66 obteve aumento do escore final e o GMFCS manteve-se no nível I. O GMFM-66 apresentou melhora de 4,99% ao final da intervenção. As atividades de achar a surpresa; colher laranjas e pescaria de tampinhas obtiveram melhora na classificação no nível do MACS quando comparadas à avaliação inicial. Os achados evidenciam melhor recrutamento muscular, com refinamento nos movimentos de flexão de cotovelo; supinação do antebraço e rotação externa (RE) de ombro (AU)

Quantifying long-term upper-limb activity using wearable motion sensors after nerve reconstruction for neonatal brachial plexus palsy.

OBJECTIVE: Standard, physician-elicited clinical assessment tools for the evaluation of function after nerve reconstruction for neonatal brachial plexus palsy (NBPP) do not accurately reflect real-world arm function. Wearable activity monitors allow for the evaluation of patient-initiated, spontaneous arm movement during activities of daily living. In this pilot study, the authors demonstrate the feasibility of using body-worn sensor technology to quantify spontaneous arm movement in children with NBPP 10 years after nerve reconstruction and report the timing and magnitude of recovered arm movement. METHODS: Eight children with NBPP who underwent brachial plexus reconstruction approximately 10 years prior were recruited to take part in this single-institution prospective pilot study. Per the treatment protocol of the authors' institution, operated patients had severe, nonrecovering nerve function at the time of surgery. The patients were fitted with an activity monitoring device on each of the affected and unaffected arms, which were worn for 7 consecutive days. The duration (VT) and power (VM) with which each arm moved during the patient's normal daily activities were extracted from the accelerometry data and ratios comparing the affected and unaffected arms were calculated. Demographic data and standard physician-elicited clinical measures of upper-extremity function were also collected. RESULTS: Three children underwent nerve grafting and transfer and 5 children underwent graft repair only. The mean (± SD) active range of motion was 98° ± 53° for shoulder abduction, 130° ± 24° for elbow flexion, and 39° ± 34° for shoulder external rotation. The median Medical Research Council grade was at least 2.5 for all muscle groups. The median Mallet grade was at least 2 for all categories, and 13.5 total. The VT ratio was 0.82 ± 0.08 and the VM ratio was 0.53 ± 0.12. CONCLUSIONS: Wearable activity monitors such as accelerometers can be used to quantify spontaneous arm movement in children who underwent nerve reconstruction for NBPP at long-term follow-up. These data more accurately reflect complex, goal-oriented movement needed to perform activities of daily living. Notably, despite severe, nonrecovering nerve function early in life, postsurgical NBPP patients use their affected arms more than 80% of the time that they use their unaffected arms, paralleling results in patients with NBPP who recovered spontaneously. These data represent the first long-term, real-world evidence to support brachial plexus reconstruction for patients with NBPP.

Surgical timing in neonatal brachial plexus palsy: A PRISMA-IPD systematic review.

BACKGROUND: Neonatal brachial plexus palsy (NBPP) is a serious complication of high-risk deliveries with controversy surrounding timing of corrective nerve surgery. This review systematically examines the existing literature and investigates correlations between age at time of upper trunk brachial plexus microsurgery and surgical outcomes. METHODS: A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA-IPD guidelines was conducted in January 2020 to include full-text English papers with microsurgery in upper trunk palsy, pediatric patients. Spearman rank correlation analysis and two-tailed t-tests were performed using individual patient data to determine the relationship between mean age at time of surgery and outcome as determined by the Mallet, Medical Research Council (MRC), or Active Movement Scale (AMS) subscores. RESULTS: Two thousand nine hundred thirty six papers were screened to finalize 25 papers containing individual patient data (n = 256) with low to moderate risk of bias, as assessed by the ROBINS-I assessment tool. Mallet subscore for hand-to-mouth and shoulder abduction, AMS subscore for elbow flexion and external rotation, and MRC subscore for elbow flexion were analyzed alongside the respective age of patients at surgery. Spearman rank correlation analysis revealed a significant negative correlation (ρ = -0.30, p < .01, n = 89) between increasing age (5.50 ± 2.09 months) and Mallet subscore for hand-to-mouth (3.43 ± 0.83). T-tests revealed a significant decrease in Mallet hand-to-mouth subscores after 6 months (p < .05) and 9 months (p < .05) of age. No significant effects were observed for Mallet shoulder abduction, MRC elbow flexion, or AMS elbow flexion and external rotation. CONCLUSION: The cumulative evidence suggests a significant negative correlation between age at microsurgery and Mallet subscores for hand-to-mouth. However, a similar correlation with age at surgery was not observed for Mallet shoulder abduction, MRC elbow flexion, AMS external rotation, and AMS elbow flexion subscores.

Evaluation of Long-Term Results of Oberlin Surgery in Obstetric Brachial Paralysis / Avaliação dos resultados a longo prazo da cirurgia de Oberlin na paralisia braquial obstétrica

Abstract Objective To evaluate elbow flexion in children with obstetric brachial plexus paralysis submitted to Oberlin transfer. Methods Retrospective study with 11 patients affected by paralysis due to labor who did not present spontaneous recovery from elbow flexion until 12 months of life, operated between 2010 and 2018. Results The children were operated between 5 and 12 months of life, with a mean of 7.9 months, and the mean follow-up time was 133.2 months, ranging from 37 to 238 months. Six patients (54.5%) presented a degree of muscle strength ≥ 3, measured by the strength scale of the Medical Research Council (MRC) and, according to the active movement scale (AMS), 5 patients obtained a score of ≥ 5. A negative correlation was identified between the AMS and the Narakas classification (r = -0.509), as well as between the strength scale (MRC) and the Narakas classification (r = -0.495). A strong positive correlation was observed (r = 0.935) between the AMS and the MRC demonstrating that the higher the score on the movement scale, the higher the score on the muscle strength scale. Conclusion The Oberlin surgery is a possible option for recovery of elbow flexion in children with neonatal plexopathy, demonstrating, however, very heterogeneous results, even in the long-term follow-up.

Resumo Objetivo Avaliar a flexão do cotovelo em crianças portadoras de paralisia obstétrica do plexo braquial submetidas à transferência de Oberlin. Métodos Estudo retrospectivo com 11 pacientes acometidos por paralisia decorrente do trabalho de parto e que não apresentaram recuperação espontânea da flexão do cotovelo até os 12 meses de vida, operados entre 2010 e 2018. Resultados As crianças foram operadas entre os 5 e 12 meses de vida, com média de 7,9 meses e o tempo médio de seguimento foi de 133,2 meses, variando de 37 a 238 meses. Seis pacientes (54,5%) apresentaram grau de força muscular ≥ 3, medido pela escala de força do Medical Research Council (MRC), e, pela escala de movimentação ativa (Active Momement Scale [AMS]), 5 pacientes obtiveram pontuação ≥ 5. Foi identificada correlação negativa entre a AMS e a classificação de Narakas (r = -0,509), bem como entre a MRC e a classificação de Narakas (r = -0,495). Já entre a AMS e a MRC, foi observada forte correlação positiva (r = 0,935), demonstrando que quanto maior a pontuação na escala de movimento, maior será a pontuação na escala de força muscular. Conclusão A cirurgia de Oberlin apresenta-se como uma opção possível para a recuperação da flexão do cotovelo em crianças com plexopatia neonatal; no entanto, demonstra resultados bastante heterogêneos, mesmo no seguimento a longo prazo.

Cinco tarefas direcionadas nas habilidades manuais de uma criança com paralisia braquial obstétrica / Five oriented tasks in manual skills of a baby child with obstetric brachial plexus palsy

RESUMO: A lesão do plexo braquial (PB) durante o parto é denominada paralisia braquial obstétrica (PBO). É uma anormalidade que ocorre na extremidade superior do corpo, em consequência de um estiramento excessivo das raízes neurais do PB. Toda habilidade motora que a criança com PBO adquirir será dificultada pela deficiência na movimentação de um membro superior (MS), repercutindo em suas experimentações motoras. Para modificar seu comportamento motor, a terapia por tarefas direcionadas pode contribuir na função do MS afetado, pois a mesma caracteriza-se com um protocolo de exercícios funcionais, que ainda há escassez em pesquisas voltados a esta morbidade. O objetivo do estudo foi avaliar o efeito de uma intervenção motora através de cinco tarefas direcionadas sobre as habilidades manuais do membro superior de uma criança com PBO, bem como sua função motora grossa. A criança do estudo tinha 17 meses, com PBO à esquerda, com fraqueza de abdução de ombro, rotação externa, flexão de cotovelo e queda do punho. Realizou 24 sessões de fisioterapia com tarefas direcionadas por 45 minutos, três vezes por semana. Para classificar o grau de severidade do MSE, foi utilizado o Manual Ability Classification System (MACS). A Medida da Função Motora Grossa (GMFM-66) mediu quantitativamente aspectos motores e estáticos e o Sistema de Classificação da Função Motora Grossa (GMFCS) foi utilizado para determinar qual nível melhor representou as habilidades e limitações na função motora grossa da criança. As tarefas direcionadas foram baseadas no modelo do protocolo de terapia por contensão induzida (TCI), sendo: achar a surpresa; colher laranja; encaixar elástico de cabelo; pescaria de tampinhas; empilhar blocos. Nas avaliações pós-intervenção, o MACS demonstrou melhora no nível das tarefas de achar a surpresa, colher laranja e pescaria de tampinhas, mas manteve-se igual no nível das atividades de encaixar os elásticos e empilhar os blocos. O GMFM-66 obteve aumento do escore final e o GMFCS manteve-se no nível I. O GMFM-66 apresentou melhora de 4,99% ao final da intervenção. As atividades de achar a surpresa; colher laranjas e pescaria de tampinhas obtiveram melhora na classificação no nível do MACS quando comparadas à avaliação inicial. Os achados evidenciam melhor recrutamento muscular, com refinamento nos movimentos de flexão de cotovelo; supinação do antebraço e rotação externa (RE) de ombro. (AU)

ABSTRACT: Brachial plexus (BP) injury during labor is called obstetric brachial palsy (OBP). It is an abnormality that occurs in the upper extremity of the body due to excessive stretching of the neural roots of the BP. Every motor skill that the child with OPB acquires will be hampered by the deficiency in the movement of an upper limb (MS), impacting his motor experimentation. To modify their motor behavior, task-directed therapy can contribute to the function of the affected upper limb, because it is characterized by a protocol of functional exercises, which is still scarce in researches aimed at this morbidity. The objective of the study was to evaluate the effect of a motor intervention by means of five directed tasks on the manual skills of the upper limb of a child with OBP, as well as on his gross motor function. The child in the study was 17 months old, with left OBP, with weakness of shoulder abduction, external rotation, elbow flexion and wrist drop. He underwent 24 physiotherapy sessions with directed tasks for 45 minutes, three times a week. The Manual Ability Classification System (MACS) was used to classify the degree of severity of the MSE. The Gross Motor Function Measure (GMFM-66) quantitatively measured motor and static aspects and the Gross Motor Function Classification System (GMFCS) was used to determine which level best represented the abilities and limitations in the child's gross motor function. The targeted tasks were based on the model of the Induced Constraint Therapy (ICT) protocol, being: find the surprise; orange spoon; hair elastic fitting; fishing for bottle caps; stacking blocks. In the post-intervention assessments, the MACS showed improvement in the tasks of finding the surprise, orange spoon, and fishing for lids, but remained the same in the level of the activities of fitting the rubber bands and stacking the blocks. The GMFM-66 obtained an increase in the final score and the GMFCS remained at the level I. The GMFM-66 showed a 4.99% improvement at the end of the intervention. The activities finding the surprise, picking oranges, and fishing for bottle caps showed an improvement in the MACS level classification compared to the initial assessment. The findings show better muscle recruitment, with refinement in elbow flexion movements, forearm supination and external rotation (ER) of the shoulder. (AU)

Surgical Innovations to Restore Function in Pediatric Peripheral Nerve Conditions.

Peripheral nerve injuries in children can result in devastating lifelong deficits. Because of the time-sensitive nature of muscle viability and the limited speed of nerve regeneration, early recognition and treatment of nerve injuries are essential to restore function. Innovative surgical techniques have been developed to combat the regenerative length and speed; these include nerve transfers. Nerve transfers involve transferring a healthy, expendable donor nerve to an injured nerve to restore movement and sensation. Nerve transfers are frequently used to treat children affected by conditions, including UE trauma, brachial plexus birth injury, and acute flaccid myelitis. Pediatricians play an important role in the outcomes of children with these conditions through early diagnosis and timely referrals. With this review, we aim to provide awareness of state-of-the-art surgical treatment options that significantly improve the function of children with traumatic nerve injuries, brachial plexus birth injury, and acute flaccid myelitis.

Nerve Graft and Nerve Transfer for Improving Elbow Flexion in Children with Obstetric Palsy. A Systematic Review / Enxerto e transferência de nervo para melhora da flexão do cotovelo em crianças com paralisia obstétrica. Uma revisão sistemática

Abstract Obstetric brachial plexus palsy is a rather common injury in newborns, caused by traction to the brachial plexus during labor. In this context, with the present systematic review, we aimed to explore the use of nerve graft and nerve transfer as procedures to improve elbow flexion in children with obstetric palsy. For the present review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the MEDLINE, EMBASE, LILACS, The Cochrane Central Register of Controlled Trials, Web of Science, Wholis and SCOPUS databases. Predetermined criteria defined the following requirements for inclusion of a study: Clinical trials, quasi-experiments, and cohort studies that performed nerve graft and nerve transfer in children (≤ 3 years old) with diagnosis of obstetric palsy. The risk of bias in nonrandomized studies of interventions assessment tool was used for nonrandomized studies. Out of seven studies that used both procedures, three of them compared the procedures of nerve graft with nerve transfer, and the other four combined them as a reconstructive method for children with obstetric palsy. According to the Medical Research Council grading system, both methods improved equally elbow flexion in the children. Overall, our results showed that both techniques of nerve graft and nerve transfer are equally good options for nerve reconstruction in cases of obstetric palsy. More studies approaching nerve reconstruction techniques in obstetric palsy should be made, preferably randomized clinical trials, to validate the results of the present systematic review.

Resumo A paralisia obstétrica do plexo braquial é uma lesão bastante comum em neonatos, sendo causada pela tração do plexo braquial durante o trabalho de parto. A presente revisão sistemática tem como objetivo exploraro uso de enxertose transferências de nervo como procedimentos para melhora da flexão do cotovelo em crianças com paralisia obstétrica. A presente revisão sistemática seguiu as diretrizes Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, na sigla em inglês) e foi baseada em pesquisa nos bancos de dados MEDLINE, EMBASE, LILACS, The Cochrane Central Register of Controlled Trials, Web of Science, Wholis e SCOPUS. De acordo com os critérios pré-determinados, os artigos incluídos eram ensaios clínicos, quase-experimentos, e estudos de coortes sobre enxertos e transferências de nervos em crianças (de até 3 anos de idade) com diagnóstico de paralisia obstétrica. A ferramenta de avaliação Risk of Bias in Non-Randomized Studies of Interventions foi usada em estudos não randomizados. Sete estudos utilizaram os dois procedimentos; três deles compararam os procedimentos de enxerto e transferência de nervo, enquanto os outros quatro os combinaram como método reconstrutivo em crianças com paralisia obstétrica. Segundo o sistema de classificação do Medical Research Council, os dois métodos melhoraram a flexão do cotovelo das crianças de maneira similar. De modo geral, nossos resultados mostraram que o enxerto de nervo e a transferência de nervo são opções igualmente boas para a reconstrução nervosa em casos de paralisia obstétrica. Mais estudos sobre as técnicas de reconstrução nervosa na paralisia obstétrica devem ser realizados, de preferência ensaios clínicos randomizados, para validação dos resultados dessa revisão sistemática.

Timing of Nerve Recovery After Nerve Grafting in Obstetrical Brachial Plexus Palsy Patients With Isolated Upper Trunk Neuromas.

BACKGROUND: The timing of nerve recovery after nerve grafting in obstetrical brachial plexus palsy patients has not been well reported. One prior study reported a return to baseline function at 3 to 6 months postoperatively. However, there is a paucity of studies to corroborate this timing, and there have been no studies delineating the timeline to obtain clinically meaningful function. METHODS: OBPP patients with upper trunk neuromas-in-continuity who were treated with resection and sural nerve grafting at a single institution were studied. Time to return to baseline function was assessed by Active Movement Scale (AMS) scores preoperatively and postoperatively. Time to clinically meaningful function, defined as an AMS score of ≥6, was also assessed. RESULTS: Eleven patients with isolated upper trunk neuromas-in-continuity underwent excision and reversed sural nerve grafting. Three of 11 patients also underwent spinal accessory to suprascapular nerve transfers. Average age at surgery was 9.8 ± 1.9 months. One patient did not have follow-up data and was excluded. Average follow-up was 37.1 ± 16.8 months. Average return to baseline AMS score was approximately 4 to 8 months for shoulder abduction, shoulder flexion, shoulder external rotation, elbow flexion, and forearm supination. Clinically meaningful function was obtained in most patients between 9 and 15 months. The remaining patients who did not achieve clinically meaningful function had all obtained scores of 5, which reflects less than one half normal range of motion against gravity. CONCLUSIONS: Nerve recovery after surgical intervention in OBPP patients who undergo resection of an upper trunk neuroma-in-continuity and nerve grafting is more rapid than in adults but longer than previously reported in OBPP literature. This study provides an important data point in delineating the timeline of nerve recovery.

Knowledge of neonatal brachial plexus palsy among medical professionals in North America.

PURPOSE: Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP. METHODS: A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge. RESULTS: Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation. CONCLUSIONS: Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.

Gripforce reduction in children with an upper neonatal brachial plexus palsy.

OBJECTIVE: To assess gripforce in children with a C5 and C6 neonatal brachial plexus palsy, as it may affect hand use. Applying classic innervation patterns, gripforce should not be affected, as hand function is not innervated by C5 or C6. This study compares gripforce in children with a neonatal brachial plexus palsy with that in a healthy control group, and assesses correlations with hand sensibility, bimanual use and external rotation. METHODS: A total of 50 children with neonatal brachial plexus palsy (mean age 9.8 years) and 25 controls (mean age 9.6 years) were investigated. Nerve surgery had been performed in 30 children, and 20 children had been treated conservatively. Gripforce of both hands was assessed using a Jamar dynamometer. Sensibility of the hands was assessed with 2-point discrimination and Semmes-Weinstein monofilaments. External rotation was assessed using the Mallet score. Bimanual use was measured by using 1 of 3 dexterity items of the Movement Assessment Battery for Children-2. The affected side of the neonatal brachial plexus palsy group was compared with the non-dominant hand of the control group using 1-way analysis of variance (ANOVA), χ2 and Mann-Whitney tests. RESULTS: The mean gripforce of the affected non-dominant hand of children with neonatal brachial plexus palsy was reduced compared with healthy controls (95 N and 123 N, respectively, with p = 0.001). The mean gripforce of the non-dominant hand in the control group was 92% of that of the dominant hand, while it was only 76% in the neonatal brachial plexus palsy group (p = 0.04). There was no relationship between gripforce reduction and sensibility, bimanual use or shoulder external rotation. DISCUSSION: The gripforce in neonatal brachial plexus palsy infants with a C5 and C6 lesion is lower than that of healthy controls, although classic interpretation of upper limb innervation excludes this finding. The reduction in gripforce in upper neonatal brachial plexus palsy lesions is not widely appreciated as a factor inherently compromising hand use. The reduction in gripforce should be taken into consideration in planning the type of rehabilitation and future activities.