Central Adaptation following Brachial Plexus Injury.

Brachial plexus trauma (BPT) often affects young patients and may result in lasting functional deficits. Standard care following BPT involves monitoring for clinical and electrophysiological evidence of muscle reinnervation, with surgical treatment decisions based on the presence or absence of spontaneous recovery. Data are emerging to suggest that central and peripheral adaptation may play a role in recovery following BPT. The present review highlights adaptive and maladaptive mechanisms of central and peripheral nervous system changes following BPT that may contribute to functional outcomes. Rehabilitation and other treatment strategies that harness or modulate these intrinsic adaptive mechanisms may improve functional outcomes following BPT.

The development and validation of an internet-based training package for the management of perineal trauma following childbirth: MaternityPEARLS.

BACKGROUND: Birth-related perineal trauma has a major impact on women's health. Appropriate management of perineal injuries requires clinical knowledge and skill. At present, there is no agreement as to what constitutes an effective clinical training programme, despite the presence of sufficient evidence to support standardised perineal repair techniques. To address this deficiency, we developed and validated an interactive distance learning multi-professional training package called MaternityPEARLS. METHOD: MaternityPEARLS was developed as a comprehensive e-learning package in 2010. The main aim of the MaternityPEARLS project was to develop, refine and validate this multi-professional e-learning tool. The effect of MaternityPEARLS in improving clinical skills and knowledge was compared with two other training models; traditional training (lectures + model-based hands on training) and offline computer lab-based training. Midwives and obstetricians were recruited for each training modality from three maternity units. An analysis of covariance was done to assess the effects of clinical profession and years of experience on scoring within each group. Feedback on MaternityPEARLS was also collected from participants. The project started in January 2010 and was completed in December 2010. RESULTS: Thirty-eight participants were included in the study. Pretraining and post-training scores in each group showed considerable improvement in skill scores (p<0.001 in all groups). Mean changes were similar across all three groups for knowledge (3.24 (SD 5.38), 3.00 (SD 3.74), 3.30 (SD 3.73)) and skill (25.34 (SD 8.96), 22.82 (SD 9.24), 20.7 (SD 9.76)) in the traditional, offline computer lab-based and e-learning groups, respectively. There was no evidence of any effect of clinical experience and baseline knowledge on outcomes. CONCLUSIONS: MaternityPEARLS is the first validated perineal trauma management e-learning package. It provides a level of improvement in skill and knowledge comparable to traditional methods of training. However, as an e-learning system, it has the advantage of ensuring the delivery of a standardised, continuously updated curriculum that has global accessibility.

Central hypoventilation and diaphragmatic eventration: diagnosis and management.

Congenital central alveolar hypoventilation syndrome (CCAHS) is a disorder of ventilatory control that occurs without neuromuscular blockade or pulmonary disease. It is characterized by a lack of response to habitual respiratory stimulants, especially hypercapnia. In this article, the management of this syndrome by diaphragmatic pacing is discussed. Paralysis of the phrenic nerve in small children usually results from injury during birth or during a cardiothoracic operation and results in eventration of the hemidiaphragm. Alternatively, eventration of the diaphragm may be a congenital condition. In both cases it may lead to respiratory distress in the newborn. In this article, we review the diagnosis of these conditions and their management, focusing on the surgical indications. We also discuss outcome.

[Obstetrical injuries of the brachial plexus]. / Porodajne povrede plexus brachialisa.

Although birth-related brachial plexus injury (BPI) was first described more than two centuries ago, it still represents therapeutic dillemma. Incidence is 0.37-2.0 per 1000 live births. The most frequent etiologic cause is extreme lateral traction and excessive fundal pressure in a case of shoulder dystocia. However, in last decade there are reports that cite of BPIs occurring prior to delivery in up to 46% cases--intrauterine maladaptation. In 1998. and 1999. at the Rehabilitation Department of Pediatric Hospital, Clinical University Center in Sarajevo 32 children with BPI were treated. The incidence is 2.67 per 1000 live births. There were 21 cases of Erb's palsy (65.63%), 2 cases of Klumpke's palsy (6.25%). Total plexus palsy was present in 9 children (28.63%), and Horner's Syndrome in 1 case. In 25.77% of cases (8 children) there was-no evidence of shoulder dystocia at delivery. Treatment of the brachial plexus injuries in newborn is still controversial. Proper immobilization in first 7-15 days is of great importance. In this study 25 children (78.13%), in average age of 4.6 days, were brought for examination with improper immobilization. The role of widely applied electrotherapy is controversial. Complete recovery is expected in about one half, and in this study it was achieved in 75% of cases (24 children). Consensus about timing od surgical approach does not exist still. However, there is strong agreement that decision about eventual surgical treatment should be based on clinical motor testing and that MRI should precede the surgery. Although the electrodiagnostic studies have proven to be of limited prognostic value in the evaluation of children with acute obstetrical brachial plexus injuries, electromyography should be performed prior the surgery in the aim of later comparison of the results. According to our data, at this particular moment in BiH surgical treatment in this age is not available, as well as use of MRI in diagnostics of BPIs.

[The diagnostic and treatment characteristics of birth injury to the brachial plexus in children and adolescents]. / Osobennosti diagnostiki i lecheniia rodovoi travmy plechevogo spleteniia u detei i podrostkov.

From 1980 to 1994, a total of 73 patients were treated at the Russian Research Surgery Institute named after A. L. Polenov for damage to the brachial plexus during birth injury. The authors proposed an original procedure for treating these patients. This involved conservative therapy, surgical intervention on the brachial plexus and correction of the arm locomotor apparatus by orthopedic techniques. The conservative treatment were performed by original methods: namely in combination with hyperbaric oxygenation, low-energy laser exposure of the brachial plexus or by administering cholinesterase agents into the bioenergetic points, followed by electrostimulation of the neuromuscular apparatus. The original conservative treatment led to a significantly improved arm function in 53% of the patients. If the conservative therapy failed, obstacles to the restoring the conduction of the brachial plexus were eliminated via operations (neurolysis, suture, autoplasty, reinnervation). The operation gave the benefit to 74% in whom conservative therapy turned out to be ineffective. If surgical recovery of the brachial plexus failed, arm locomotor intervention was applied.

Obstetrical lesions of the brachial plexus. Natural history in 34 personal cases.

34 subjects with 36 obstetrical paralysis of the brachial plexus were studied. The diagnosis was made immediately after birth in the great majority. 5 pareses of the lower plexus, however, were only recognized later. All subjects were first seen by us under the age of 13 years, 25 during the first year of life. At follow-up the age of the 34 subjects varied between 3 and 24 years. 32 patients had undergone daily physiotherapy, in 5 electrotherapy had also been applied. There was no correlation between these treatments and the outcome. Of the 20 cases of paresis of the lower plexus 3 were severely handicapped after the age of 3. This was the case for 9 of the 12 patients with total paresis. Everyday activities of these patients are influenced by the motor deficit. Even subjects with relatively serious sequelae apparently enjoy an almost normal life and have a good self-image. A significant improvement generally occurred as early as the first 3 years of life.