Assessment of Self-Determination in Adolescents with Neonatal Brachial Plexus Palsy.

BACKGROUND: The term self-determination refers to decision-making, goal setting, and perseverance to achieve those goals. Numerous studies have established the importance of self-determination to enhance learning and improve postschool outcomes. However, most studies evaluate students with learning disabilities, cognitive impairment, or behavioral disabilities. There is an absence of research on self-determination for adolescents with physical disabilities. OBJECTIVE: To assess self-determination of adolescents with neonatal brachial plexus palsy (NBPP) compared with their typically developing peers via self-reported measures of function. DESIGN: Case-control study. SETTING: Brachial plexus clinic. PARTICIPANTS: Twenty adolescents with NBPP (aged 10-17 years) and their parents and 20 age/gender-matched typically developing adolescents and their parents were recruited. Non-English-speaking participants and those with other physical impairments were excluded from study. METHODS: Participants completed demographic and American Institutes for Research (AIR) self-determination surveys. One of two designated occupational therapists evaluated participant physical function. MAIN OUTCOME MEASUREMENTS: A demographic survey and AIR self-determination assessment were administered, and active range of motion measurements in shoulder forward flexion, elbow flexion, elbow extension, forearm pronation, and supination were obtained. Grip/pinch strength, MRC muscle strength, 9-Hole Peg Test, and Mallet scale scores also were evaluated. RESULTS: Despite physical differences, adolescents with NBPP presented similar self-determination levels as their typically developing peers. Adolescents with NBPP rated their opportunities to engage in self-determined behaviors at school significantly lower than at home. Both adolescents with NBPP and those in the control group rated their opportunities to engage in self-determined behaviors at school significantly lower than at home. CONCLUSIONS: Adolescents with NBPP presented similar self-determination scores as their age/gender-matched typically developing peers. These results could be a reflection of our program's patient- and family-centered care approach. Therefore, caregivers and providers should encourage personal development and fulfillment in adolescents with NBPP. Teachers and schools should be aware that opportunities for acquiring self-determination skills might be more limited at school than at home in this age group. LEVEL OF EVIDENCE: III.

Prevalence of Posterior Shoulder Subluxation in Children With Neonatal Brachial Plexus Palsy After Early Full Passive Range of Motion Exercises.

BACKGROUND: Children with neonatal brachial plexus palsy (NBPP) are often prescribed shoulder range of motion (ROM) exercises; however, the extent and timing of exercise implementation remains controversial in the context of shoulder joint integrity. The association of ROM exercises to delayed posterior shoulder subluxation (PSS) is unknown. OBJECTIVE: To determine prevalence of PSS in children with NBPP who began full passive ROM exercises before 6 months of age, and characteristics associated with development or absence of PSS in children. DESIGN: Cross-sectional study. SETTING: Tertiary care NBPP referral center. PARTICIPANTS: Forty-six children with NBPP, aged 24-57 months, who began full ROM exercises before 6 months of age. METHODS: One radiologist conducted bilateral shoulder ultrasound (US) on each child to evaluate for PSS. One occupational therapist evaluated each child clinically for PSS using defined parameters without knowledge of US results. MAIN OUTCOME MEASURES: By US, 20% of children had PSS; 46% had PSS by clinical examination. Shoulder active ROM limitations and history of shoulder surgery were associated with presence of PSS. Extent of NBPP was not associated with PSS. RESULTS: Nine of 46 children (20%) met US criteria for PSS; α angle was 58° ± 21° (mean ± standard deviation [SD]). Twenty-one children (46%) met clinical criteria. Mean age at examination was 35 ± 10 months. Shoulder active ROM (P ≤ .004) was associated with PSS, whereas passive ROM was not (P ≥ .08). History of secondary shoulder surgery and primary nerve graft repair were associated with PSS (P = .04). Extent of NBPP by Narakas classification was not associated with PSS (P = .48). CONCLUSIONS: Early use of full-arc passive ROM home exercise program is not associated with increased prevalence of PSS in children with NBPP compared to prevalence of PSS in published literature. We suggest careful clinical examination, based on defined criteria, provides a reasonable screening examination for evaluating PSS that can be confirmed by noninvasive US.

Home exercise DVD promotes exercise accuracy by caregivers of children and adolescents with brachial plexus palsy.

OBJECTIVE: To evaluate the accuracy of home exercise performance by caregivers of children with neonatal brachial plexus palsy (NBPP) who use digital versatile disc (DVD) guidance. DESIGN: Prospective cohort study. SETTING: Brachial Plexus Clinic at the University of Michigan. PARTICIPANTS: Seventy-six adult caregivers of a consecutive cohort of pediatric patients with NBPP. METHODS: Caregivers received the Home Exercise Program for Brachial Plexus Palsy DVD and an initial demonstration of correct hand placement and movement patterns by 1 of 2 occupational therapists. At times A, B, and C (approximately 3, 6, and 12 months), caregiver accuracy in exercise performance at each joint and standard measurements of arm function were recorded. MAIN OUTCOME MEASUREMENTS: Caregiver accuracy in correct hand placement and movement pattern during exercise performance was evaluated with use of a dichotomy scale (yes/no) at each joint. Active and passive range of motion were assessed as indicators of arm function. RESULTS: The mean patient age was 38 months, and the median Narakas score was 2. No significant difference in exercise accuracy for all upper extremity joints between the initial evaluation and times A, B, and C or between individual times was observed, except at the shoulder (98.9% initially to 88.3% at time A; P = .0002) and elbow (100% initially to 96.6% at time A; P = .04). Regarding arm function, an increase in active range of motion for shoulder flexion, elbow flexion, forearm supination, wrist extension, and finger flexion was observed during the study period. CONCLUSIONS: Shoulder and elbow exercises may be more complex, requiring more frequent performance review with the caregiver. However, the home exercise DVD may benefit patients with NBPP and their caregivers and may provide an adjunct to formal therapy sessions.

An assessment of the compliance and utility of a home exercise DVD for caregivers of children and adolescents with brachial plexus palsy: a pilot study.

OBJECTIVE: To investigate the impact of a video-based educational resource on home exercise compliance among caregivers of children with neonatal brachial plexus palsy (NBPP). DESIGN: Retrospective analysis of self-reported caregiver home exercise habits and resultant shoulder range of motion (ROM) and biceps power in patients with NBPP. SETTING: Home-based exercise program. PARTICIPANTS: Adult caregivers of children with NBPP followed up through the Brachial Plexus Program at the University of Michigan (N = 83 surveyed initially, with N = 37 completing the final survey). METHODS: Caregivers completed surveys before and approximately 3, 6, and 12 months (times A, B, and C, respectively) after receiving the "Home Exercise Therapy Program for Brachial Plexus Palsy" digital video disk (DVD). A retrospective analysis of shoulder ROM and biceps power of patients was completed as representative of arm function during the study. MAIN OUTCOME MEASUREMENTS: Surveys assessed home exercise compliance, resources used to guide exercises, and caregiver confidence in the correctness of exercises being performed. Functional outcomes analyzed include biceps strength and shoulder active and passive ROM. RESULTS: Home exercise compliance increased from 74% initially to 96% at time A (P < .001), remained at 94% at time B (P < .001), and fell to 84% at time C (P = .016). Use of the DVD to guide home exercise decreased from 69% at time A to 57% at time B and C (P = .026). After receiving the DVD, exercise frequency and caregiver confidence increased. Although some measures of shoulder active ROM and biceps power improved during the course of the study, there was no consistent statistically significant relationship between increased caregiver confidence and functional outcomes. No causal relationship exists between DVD content and functional status at this time. CONCLUSIONS: As the first formal evaluation of a video-based resource guiding exercise therapy for children with NBPP, we suggest that this population may be receptive to alternative media and may benefit from dynamic modeling of home exercises.