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)

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)

Therapeutic Implementation of a Custom Dynamic Elbow Brace for Children With Neonatal Brachial Plexus Palsy: A Case Report.

PURPOSE: The objective of this analysis is to present the benefits and functional outcomes when using a custom dynamic elbow brace as an adjunct to therapeutic interventions for a child with neonatal brachial plexus palsy. SUMMARY OF KEY POINTS: Impairments associated with neonatal brachial plexus palsy can cause lifelong limitations of mobility, dexterity, and functional use of the involved upper extremity. The functional design of the custom dynamic elbow brace provided therapeutic versatility including immobilization, active-assisted controlled movement, and resistance exercise. These features facilitated efficient and functional muscle activation patterns, negating compensatory or substitute movements. CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE: The brace provided opportunities for focused muscle activation and subsequent improvements in strength, development of motor control, and functional mobility. Using a custom dynamic elbow brace was an effective therapeutic tool, used in conjunction with a comprehensive treatment program, and contributed to a successful outcome.

Constraint-induced movement therapy for children with neonatal brachial plexus palsy: a randomized crossover trial.

AIM: To determine if constraint-induced movement therapy (CIMT) is more effective than standard care in improving upper-limb activity outcomes in children with neonatal brachial plexus palsy (NBPP). METHOD: Twenty-one children with NBPP (mean age 25mo, SD=10.3, range=17-48mo; 11 males, 10 females) were enrolled in a crossover trial and randomly allocated to first receive CIMT or standard care, each for 8 weeks. The intervention arm consisted of 3 weeks of casting the unaffected limb followed by 5 weeks of transference activities. The Assisting Hand Assessment (AHA) was used to measure bimanual activity performance at baseline, 8 weeks, and 16 weeks, scored by blinded raters. The Pediatric Motor Activity Log-Revised (PMAL-R) was used as a caregiver-reported secondary outcome measure. RESULTS: After concealed random allocation (n=21), there were no significant differences on demographics or baseline measures. CIMT was superior compared to control in terms of bimanual activity performance with a mean difference in AHA change score of 4.8 (SD=10.5, p=0.04, Cohen's δ=0.46). There were no significant differences between treatment conditions on the PMAL-R. INTERPRETATION: CIMT is favored over standard care for bimanual activity performance. Future research should investigate a longer follow-up period, additional comparator interventions, and analyse differences by participant characteristics. WHAT THIS PAPER ADDS: Gains in bimanual activity performance were greater after constraint-induced movement therapy (CIMT) compared to no CIMT. Frequency and quality of movement were not significantly different between treatment groups.

Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function.

BACKGROUND: Shoulder release and tendon transfer is frequently performed to address persistent weakness from neonatal brachial plexus palsy. Although postoperative improvements in motion are well described, associated deficits are poorly documented, and functional assessments are lacking. Loss of ability to reach midline can occur with surgery and may result in impairment. The purpose of this study was to comprehensively assess the gains, losses, functional changes, and patient-reported outcome associated with the authors' surgical approach. METHODS: Consecutive patients undergoing surgery with 2-year follow-up were included (n = 30). Prospectively recorded assessments by therapists were reviewed. Changes were assessed by t test and Wilcoxon rank sum (p < 0.05). RESULTS: Active external rotation and abduction improved and internal rotation diminished. Aggregate modified Mallet score increased with improvements in all subscales, except that hand to spine was unchanged and hand to belly decreased. Functional assessment using the Brachial Plexus Outcome Measure revealed an increase of aggregate score, with no decline in any subscales. Improvements were in hand to back of head, forward overhead reach, holds plate with palm up, opening large container, and strings bead. Aggregate patient self-report of appearance and function increased (from 18 to 23). Loss of ability to reach midline occurred in three patients (10 percent) who had extended Erb or total palsy and preoperative limitations of internal rotation. CONCLUSIONS: Secondary reconstruction rebalances shoulder motion by increasing external rotation and abduction and reducing internal rotation. In this study, a conservative surgical approach results in overall improvement in task-based abilities and self-reported outcomes and preservation of internal rotation within a functional range. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Modified constraint-induced movement therapy during hospitalization in children with perinatal brachial plexus palsy: A randomized controlled trial.

STUDY DESIGN: Prospective single-blind, randomized controlled study. INTRODUCTION: Children with perinatal brachial plexus palsy (PBPP) have motion limitations in the affected upper extremity. Modified constraint-induced movement therapy (mCIMT) is one of the treatment options used for the improvement of the function of the affected limb. PURPOSE OF THE STUDY: The purpose of this study was to compare the effect of mCIMT and conventional therapy in improving active range of motion (ROM) and functional use of the affected upper extremity in children with PBPP with injuries to upper and middle trunks in the hospital environment. MATERIALS: 26 patients received conventional rehabilitation program (control group) and 13 patients participated in a mCIMT program (study group). Children had a mean age 56.3 months (range 4-10 years). The mCIMT included 1 hour therapy sessions emphasizing the affected arm use for 14 consecutive days during hospitalization. Their normal arm was also constrained for 6 hour per day. All the patients were assessed at the baseline, one day, one month, and three months after completion of therapy using active ROM, active movement scale, hand dynamometer, box and blocks test. RESULTS: The mCIMT group improved more than the control group in shoulder internal rotation, forearm supination, elbow flexion active ROMs, hand grip strength, and in upper extremity function. CONCLUSION: mCIMT has a potential to promote functional gains for children with PBPP; this approach should be widely applied within routine clinical practice.

Recommendations for management of neonatal brachial plexus palsy: Based on clinical review.

STUDY DESIGN: Descriptive report. INTRODUCTION: Neonatal brachial plexus palsy (NBPP) involves a partial or total injury of the nerves that originate from spinal roots C5-C8 and T1. The reported incidence of NBPP is between 0.38 and 5.1 in 1000 births. PURPOSE OF THE STUDY: This study describes the management NBPP in the first 3 years of life and to develop an assessment framework for infants with NBPP and postoperative guidelines for those undergoing primary surgery. METHODS: Retrospective medical record audit from 2012 to 2017. RESULTS: Of 187 children referred to brachial plexus clinic (BPC), 138 were new referrals and included in the audit. The average number of new referrals per annum was 37; average age at referral was 6.61 week; average age at first appointment was 16.9 weeks. Of the 138 infants, 104 were initially assessed by a physiotherapist before attending BPC. The most common comorbidity was plagiocephaly. DISCUSSION: From 2012 to 2017, birth location, birth facility, referral source, and time between referral and initial assessment have remained stable. The age at referral, age at which the child was first assessed, and the number of children who received services externally before attending the hospital all decreased. The number of children seen by a physiotherapist before attending BPC increased. An NBPP assessment framework, including critical time points for assessment, and postoperative guidelines for infants and children undergoing primary surgery were created. CONCLUSIONS: Early referral is essential for effective management of NBPP and ideally infants should be assessed and management implemented before 3 months of age.

Functional outcomes of tendon transfer for brachial plexus birth palsy using the Hoffer technique.

AIMS: To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP). METHODS: All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up. RESULTS: All patients demonstrated statistically significant improvement in all functional outcomes and active shoulder abduction and external rotation ROM (p < 0.001). Patients < 2.5 years of age had higher postoperative AMS, abduction ROM and strength scores, and aggregate postoperative Toronto scores (p ≤ 0.035) compared to patients ≥ 2.5 years old. There were 17 patients (16%) who required a subsequent humeral derotational osteotomy; lower preoperative AMS external rotation scores and external rotation ROM were predictive risk factors (p ≤ 0.016). CONCLUSION: Patients with BPBP who underwent the Hoffer procedure demonstrated significant improvement in postoperative ROM, strength, and functional outcome scores at mid-term follow-up. Patients younger than 2.5 years at the time of surgery generally had better functional outcomes. Limited preoperative external rotation strength and ROM were significantly associated with requirement for subsequent humeral derotational osteotomy. In our chort significant improvements in shoulder function were obtained after the Hoffer procedure for BPBP. Cite this article: Bone Joint J 2020;102-B(2):246-253.

Health-care use and information needs of children with neonatal brachial plexus palsy: A cross-sectional survey among 465 Dutch patients.

To investigate health-care use (HCU) and information needs of children aged 0-18 years with neonatal brachial plexus palsy (NBPP), a cross-sectional study was performed. Patients and/or parents seen in our NBPP clinic were invited to complete a survey comprising questions on HCU due to NBPP and current information needs. Outcomes were described for three age-groups (0-1/2-9/10-18 years), based on follow-up status (early/late/no-discharge). Four hundred sixty-five parents/patients participated (59 in the 0-1, 226 in the 2-9, and 180 in the 10-18-year group). Two hundred ninety-three patients had C5-C6 lesions, 193 were discharged from follow-up, 83 of whom categorized as 'early discharged' (<1 year of age). Over the past year, 198 patients had contact with the expert team (49 in the 0-1, 81 in the 2-9, and 68 in the 10-18-year group) and 288 with at least one other health-care professional (53 in the 0-1, 133 in the 2-9, and 102 in the 10-18-year group). Of the 83 patients discharged early, 34 reported health-care use. Two hundred twenty-eight participants reported current information needs of whom 23 were discharged early. HCU and information needs of Dutch children with NBPP remains considerable even in children who were discharged. Stricter follow-up and information provision for these patients is needed.

Leap Motion Controller-based training for upper extremity rehabilitation in children and adolescents with physical disabilities: A randomized controlled trial.

STUDY DESIGN: Randomized controlled trial. INTRODUCTION: Juvenile idiopathic arthritis (JIA), cerebral palsy (CP), and brachial plexus birth injury (BPBI) are the most common disorders that cause upper extremity impairments in children and adolescents. Leap Motion Controller-based training (LMCBT) is a novel therapeutic method for upper extremity rehabilitation. PURPOSE OF THE STUDY: The aim of the present study was to investigate the potential efficacy of an 8-week LMCBT program set as an upper extremity rehabilitation program by comparing conventional rehabilitation program in children and adolescents with physical disabilities such as JIA, CP, and BPBI. METHODS: A randomized control trial which included children and adolescents of different disabilities (JIA, CP, BPBI) were grouped according to their diagnosis. All patients were randomized into 2 groups namely LMCBT (group I) and conventional treatment (group II) for the treatment (3 days/8 weeks). Duruoz Hand Index and Jebson Taylor Hand Function Test were used as primary outcomes. Secondary outcomes included the nine-hole peg test, Childhood Health Assessment Questionnaire, and assessments of grip and pinch strength using a dynamometer. RESULTS: One hundred three patients were included in the study, and 92 of them completed the treatment. After treatment, significant differences were found in Childhood Health Assessment Questionnaire, Duruoz Hand Index, Jebson Taylor Hand Function Test, nine-hole peg test, and grip and pinch strength scores in almost all groups (effect size [ES] = 0.10 to -0.77 for group I and 0.09 to -0.70 for group II in CP; ES = 0.31 to 2.65 for the group I and 0.12 to 1.66 for group II in JIA; and ES = 0 to -0.44 for group I and 0.08 to -0.62 for group II in BPBI) (P < .05). Comparisons between LMCBT and conventional treatment groups showed similar results in all parameters in all disease groups (P > .05). CONCLUSIONS: This study has quantitatively shown that LMCBT should be used as an effective alternative treatment option in children and adolescents with physical disabilities.

Timing of rehabilitation in children with obstetric upper trunk brachial plexus palsy.

OBJECTIVES: The initiation timing of rehabilitation in children with obstetric brachial plexus palsy is controversial. The aim of the present study is to evaluate the effectiveness of rehabilitation timing to the functional outcomes of patients with obstetric upper trunk brachial plexus palsy. MATERIAL AND METHODS: Twenty-nine patients, who did not previously received any rehabilitation programme but attended our outpatient clinic, were included for the study. The electrophysiological findings, obstetric characteristics, and demographic features of the patients were recorded. The range of motion (ROM) of shoulders, elbows, and wrists and the strength of the muscles associated with these joints were evaluated. Modified Mallet Scale (MMS) was used for functional evaluation. A 4-week rehabilitation programme was performed twice at 2-month intervals. Patients were divided into three groups according to their ages as follows: 1-3 years old (group 1), 3-5 years old (group 2), and 5-7 years old (group 3). The ROMs, muscle strengths, and MMS scores of the patients were all evaluated. RESULTS: Two out of 29 patients were female (6.9%) and 27 were male (93.1%). All 29 patients had right upper extremity palsy (100%). The MMS scores, ROMs, and muscle strength of the upper extremities had improved in all the groups following the standardized rehabilitation programme. CONCLUSIONS: A rehabilitation programme is the best choice of treatment before surgical procedures in patients with mild to moderate obstetric upper trunk brachial plexus palsy regardless of age and the initiation time.

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.