Team Approach: Management of Brachial Plexus Birth Injury.

Brachial plexus birth injury is an upper-extremity paralysis that occurs from a traction injury to the brachial plexus during birth. Approximately 10% to 30% of children with a brachial plexus birth injury have residual neurologic deficits with associated impact on upper-limb function. Management of brachial plexus birth injuries with a multidisciplinary team allows optimization of functional recovery while avoiding unnecessary intervention. Early occupational therapy should be initiated with a focus on range of motion and motor learning. The need for microsurgical reconstruction of the brachial plexus can be predicted based on early physical examination findings, and reconstruction is generally performed at 3 to 9 months of age. The majority of children with residual neurologic deficits develop associated glenohumeral dysplasia. These children may require secondary procedures, including botulinum toxin injection, subscapularis and pectoralis lengthening, shoulder capsular release, shoulder tendon transfer, and humeral osteotomy.

Integrated Electromyography: Discriminant Analysis and Prediction of Recovery 3 to 6 Years After Brachial Plexus Birth Injury.

PURPOSE: To assess the recovery likelihood, 3 to 6 years after brachial plexus birth injury (BPBI), and predict the functional recovery from integrated electromyography (IEMG). METHODS: Thirty children with BPBI limited to C5-C6 lesion participated. Maximal electromyography activity of deltoid and biceps brachii was measured at entry. Shoulder and elbow functions were assessed at the baseline and at 4 intervals across 2 years. RESULTS: Shoulder and elbow function significantly changed across the follow-up period. Shoulder and elbow functions were significantly dependent on deltoid and biceps brachii muscles' IEMG level, respectively, with the groups showing higher IEMG achieving better recovery. The deltoid and biceps IEMG explained a portion of the improvement in shoulder and elbow function over 2 years. CONCLUSION: Recovery of the shoulder and elbow function continues 3 to 6 years after BPBI. IEMG may partially explain variation in the prognosis for children with BPBI.

Restoration of shoulder motion using single- versus dual-nerve repair in obstetrical brachial plexus injury.

OBJECTIVE The purpose of this study was to compare shoulder abduction and external rotation (ER) after single-nerve repair of the upper trunk alone versus dual-nerve repair of both the upper trunk and the suprascapular nerve. METHODS A retrospective chart review of a single surgeon's experience repairing obstetrical brachial plexus injuries between June 1995 and June 2015 was performed. Eight patients underwent repair of the upper trunk alone, and 10 patients underwent repair of the upper trunk and the suprascapular nerve. Shoulder abduction and ER ranges of motion (ROMs) (in degrees) were recorded preoperatively and postoperatively. Postoperative ROM and the difference in ROM gained after surgery were compared by independent t-test analysis. RESULTS The mean follow-up time was 161.4 weeks (range 62-514 weeks, SD 124.0 weeks). The mean patient age at the time of surgery was 31.3 weeks (range 19.9-47.0 weeks, SD 6.9 weeks). The mean postoperative shoulder abduction ROMs were 145.0° (range 85°-180°, SD 39.4°) after single-nerve repair and 134.0° (range 90°-180°, SD 30.3°) after dual-nerve repair (p = 0.51). The mean postoperative shoulder ER ROMs were 67.5° (range 10°-95°, SD 28.8°) after single-nerve repair and 72.0° (range 10°-95°, SD 31.3°) after dual-nerve repair (p = 0.76). CONCLUSIONS The authors found no difference in shoulder abduction and ER between patients who underwent single-nerve repair of the upper trunk alone and those who underwent dual-nerve repair of both the upper trunk and the suprascapular nerve.

Effect of virtual reality versus conventional physiotherapy on upper extremity function in children with obstetric brachial plexus injury.

OBJECTIVES: The objective was to evaluate the effects of virtual reality versus conventional physiotherapy on upper extremity function in children with obstetric brachial plexus injury. METHODS: Forty children with Erb's palsy were selected for this randomized controlled study. They were assigned randomly to either group A (conventional physiotherapy program) or group B (virtual reality program using Armeo® spring for 45 min three times/week for 12 successive weeks). Mallet system scores for shoulder function and shoulder abduction, and external rotation range of motion (ROM) were obtained; shoulder abductor, and external rotators isometric strength were evaluated pre-and post-treatment using Mallet scoring system, standard universal goniometer, and handheld dynamometer. RESULTS: The results of this study indicate that the children in both groups showed improvement in shoulder functions post-treatment with greater improvements in group B. The abduction muscle strength after treatment was 8.53 and 11.3 Nm for group A and group B, respectively. The external rotation muscle strength after treatment was 5.88 and 7.45 Nm for group A and group B, respectively. CONCLUSIONS: The virtual reality program is a significantly more effective than conventional physiotherapy program in improving the upper extremity functions in children with obstetric brachial plexus injury.

Obstetrical Brachial Plexus Palsy.

Obstetrical brachial plexus palsy is a disorder of the peripheral nervous system and occurs in as many as 0.4% of infants born. It is associated with shoulder dystocia, use of mechanical extraction, and macrosomia; it occurs more frequently in infants born by vaginal delivery. The unilateral injury to the brachial plexus complex occurs during the delivery phase as lateral traction is applied to the head to permit shoulder clearance. The infant typically presents in the delivery room with decreased active movements of the affected arm and asymmetrical primitive reflex responses. The severity of nerve involvement can range from a stretch injury to complete avulsion. While full recovery is possible, prognosis is variable and up to 35% of children may have some degree of life-long functional impairment of the affected limb.

Development of an effective therapy and objective assessment for children with birth injuries.

Sitting in a Huple, a patented hemisphere-like tool, permanently stimulates the vestibular system, thus improving the balancing ability of children with movement disorders. The Gézengúz Foundation for Children with Birth Injuries has been successfully applying this tool in therapy. By attaching x-Inertial Measurement Unit, a wireless three-dimensional orientation sensor, to the Huple, it can serve as an input peripheral for simple PC games. Children are thus motivated; they willingly perform balance training as well as participate in the game-like test. This improves the accuracy and reproducibility of the assessment. Knowing the actual state of the participants is an important element of feedback for the therapy. This paper describes in detail the development of the therapeutic and assessment method on the basis of the Huple: the definition of the movement pattern, the parameters characterizing the movement, and the algorithms used to rank children. Measurement series of 10 children with movement disorders validate the effectiveness of the game-like assessment.

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.

Obesity in children with brachial plexus birth palsy.

Fetal macrosomia is associated with a 14-fold increased risk of brachial plexus birth palsy (BPBP), and is a predictor of childhood obesity. The purpose of this study was to identify the relationships between BPBP, fetal macrosomia, and childhood obesity. We retrospectively reviewed 214 children with BPBP. The average age was 8 years and 53% had a Narakas 1 grade BPBP. Overall, 49% of children were normal weight, 22% overweight, and 29% obese. Of the children with a history of fetal macrosomia, 41% were obese; a statistically significant difference. Overall quality of life scores, however, were not correlated with obesity.

Transient neonatal radial nerve palsy. A case series and review of the literature.

Transient neonatal radial nerve palsy manifests at birth by wrist drop and intact elbow and shoulder function. Spontaneous resolution is universal. We present a case series, including two bilateral cases, and a review of the cases found in the English literature, hypothesizing how this condition is probably misdiagnosed as brachial plexus injury.

Clinical assessment of the infant and child following perinatal brachial plexus injury.

STUDY DESIGN: Literature review. INTRODUCTION: After perinatal brachial plexus injury (PBPI), clinicians play an important role in injury classification as well as the assessment of recovery and secondary conditions. Early assessment guides the initial plan of care and influences follow-up and long-term outcome. PURPOSE: To review methods used to assess, classify and monitor the extent and influence of PBPI with an emphasis on guidelines for clinicians. METHODS: We use The International Classification of Functioning, Disability, and Health (ICF) model to provide a guide to assessment after PBPI for rehabilitation clinicians. DISCUSSION: With information gained from targeted assessments, clinicians can design interventions to increase the opportunities infants and children have for optimal recovery and to attain skills that allow participation in areas of interest.

Therapeutic application of electrical stimulation and constraint induced movement therapy in perinatal brachial plexus injury: A case report.

Infants and children with perinatal brachial plexus injury (PBPI) have motion limitations in the shoulder, elbow, forearm and hand that are dependent on the level of injury and degree of recovery. The injury and subsequent recovery period occur during critical periods of central and spinal neural development placing infants and children at-risk for developmental disregard and disuse of the affected arm and hand. A case report outlines the therapy and surgical interventions provided in the first 2 years of life for a child with global PBPI and a positive Horner's sign. Electrical stimulation and constraint induced movement therapy provided sequentially were effective therapy interventions. Neurosurgery to repair the brachial plexus was performed at an optimal time period.(2) The Assisting Hand Assessment,(12) Modified Mallet(13) and Active Movement Scale(14) are effective outcome measures in PBPI and served as valuable guides for therapy intervention. Oxford Level of Evidence: 3b; Individual Case Control Study.

[Dynamics of the cognitive function in the school-age children presenting with a natal injury to the cervical spine in the course of the combined spa and health resort-based treatment with the use of manual therapy].

AIM: The objective of the present work was to study dynamics of the cognitive function in the school-age children presenting with a natal injury in the cervical region of the spine in the course of the combined spa and health resort-based treatment with the use of manual therapy based at a health resort facility. THE PATIENTS AND METHODS: A total of 110 schoolchildren at the age from 8 to 15 years (mean age 13.0 ± 0.4 years) were examined during the residual period of a natal injury in the cervical region of the spine. All the participants of the study were divided into to randomized groups. The main group was comprised of 55 school-age children (mean age 13.0 ± 0.4 years) given the comprehensive spa and health resort-based treatment with the application of manual therapy and the group of comparison that contained the remaining 55 schoolchildren (mean age 13.0 ± 0.4 years) who received the same balneotherapeutic treatment but without manual therapy. We analyzed the indicators of cognitive function after the application of manual therapy in 55 children and adolescents aged from 8 to 15 years who underwent the natal trauma to the cervical spine associatedwith the symptoms of postural disorders of varying severity. RESULTS AND DISCUSSION: The article presents the results of the analysis of cognitive function dynamics in the children and adolescents under the influence of the combined spa and health resort-based treatment with the use of manual therapy of functional blocks. It was shown that the combined spa and health resort-based rehabilitative treatment with the use of the manual therapeutic techniques makes it possible to significantly improve the condition of the cervical spine and exerts the positive influence on the dynamics of the cognitive function, has beneficial effect on the mental and motor functions, increases the flexibility and backup capabilities of the nervous system, and may be instrumental in resolving the problems arising from school disadaptation.

Computer adaptive test approach to the assessment of children and youth with brachial plexus birth palsy.

This study examined the psychometric properties of item pools relevant to upper-extremity function and activity performance and evaluated simulated 5-, 10-, and 15-item computer adaptive tests (CATs). In a multicenter, cross-sectional study of 200 children and youth with brachial plexus birth palsy (BPBP), parents responded to upper-extremity (n = 52) and activity (n = 34) items using a 5-point response scale. We used confirmatory and exploratory factor analysis, ordinal logistic regression, item maps, and standard errors to evaluate the psychometric properties of the item banks. Validity was evaluated using analysis of variance and Pearson correlation coefficients. Results show that the two item pools have acceptable model fit, scaled well for children and youth with BPBP, and had good validity, content range, and precision. Simulated CATs performed comparably to the full item banks, suggesting that a reduced number of items provide similar information to the entire set of items.

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.

[Management of upper obstetrical brachial plexus palsy. Long-term results of non-operative treatment in 22 children]. / Traitement conservateur des paralysies obstétricales hautes du plexus brachial. Résultats à long terme chez 22 enfants.

INTRODUCTION: Treatment of obstetrical brachial plexus palsy (OBPP) is always debated, especially for upper plexus palsy. Some authors perform early surgical treatment in case of absence of biceps contraction at the age of 3 months. Others prefer to wait until the age of 6 months before considering a surgical procedure when no suspicion of root avulsion is found. We think that a conservative approach with intensive rehabilitation program can obtain good functional outcome for patients who will recover biceps function spontaneously between 3 and 6 months, and that it is not necessary to perform surgery at 3 months. To argue our choice, we have compared the long-term outcome of two groups of children with upper OBPP conservatively treated regarding the age of biceps recovery (before or after 3 months). PATIENTS AND METHODS: Twenty-two patients with non operated upper roots birth palsy, followed in Timone's Hospital of Marseille by a multidisciplinary team, have recovered a biceps contraction between 1 and 8 months and were retrospectively included in this study. All children underwent an intensive rehabilitation program since birth, performed by a specialized physiotherapist. Patients were reviewed, and their shoulder function was assessed using Mallet score. The score was analysed regarding the age of biceps recovery. RESULTS: The mean follow up was 8.2 years. Nine children recovered a biceps contraction at 3 months of age or before; the mean global Mallet score was 4.11. Thirteen children recovered a biceps contraction after 3 months of age (between 3 and 8 months); the mean global Mallet score was 3.92. The difference was not statistically significant. CONCLUSION: This study shows that global shoulder function is comparable for two groups. The children who did not recover a biceps contraction at 3 months of age had a global shoulder function as good as the one who recovered biceps function earlier. We think our intensive rehabilitation program allowed us to avoid a useless early surgery. Surgical plexus treatment was indicated for children who did not have biceps contraction after 6 months of age.

Burnout, depression and anxiety levels in mothers of infants with brachial plexus injury and the effects of recovery on mothers' mental health.

OBJECTIVE: To evaluate depression, anxiety and burnout in mothers of infants with brachial plexus injury and assess the effects of the severity of injury on the mothers' mental health, as the literature provides no information on this topic. STUDY DESIGN: The study was based on eighteen mothers without psychiatric antecedents who had infants with perinatal brachial plexus paralysis (PBPP). The severity of the brachial plexus injury was classified according to the Narakas classification system. The recovery rate following conservative treatment was classified according to the Modified Mallet Classification System. The Maslach burnout inventory, Beck depression inventory, and Beck anxiety inventory were administered to the mothers. RESULTS: The mothers whose infants were in the third Narakas group were mildly depressed and the depression scores of the mothers in Narakas groups II and III were regularly increased. Mothers in the first and second groups reported a minimal level of anxiety scores. There was no statistically significant difference between the depression, anxiety, emotional exhaustion, depersonalization, and personal accomplishment scores of the mothers in relation to the severity of the injury in the child (p=0.218, p=0.078, p=0.149, p=0.138, and p=0.246). In addition, the depression and anxiety levels of the mothers whose infants recovered fully or partially showed a statistically significant decrease when compared to the mothers of infants with no recovery (p=0.003, p=0.015). There was, however, no statistically significant difference between the emotional exhaustion, depersonalization, and personal accomplishment scores of the mothers of infants with full recovery, partial recovery and no recovery (p=0.591, p=0591, p=0.062). CONCLUSION: Infants' disability may cause psychological distress in their mothers. When brachial plexus injury is predicted in infants, more mothers may become depressed.

[Splints in birth-related brachial plexus injuries]. / Zur Schienenbehandlung bei geburtstraumatischen Läsionen des Plexus brachialis.

Most cases of obstetrical brachial plexus palsies are mild traction injuries which resolve under physical therapy within several weeks or months. Severe ruptures or avulsion injuries of the plexus can lead to lifelong impairment of the upper extremities. Hence, in severe brachial plexus injuries the indications for brachial plexus reconstruction should be evaluated, early. At the age of about 3 months, the infant should be presented in a centre specialised in obstetrical brachial plexus palsies. In almost all cases intensive physical therapy is performed. In addition, many patients require splinting in order to gain function as part of the conservative therapy or for postoperative fixation. Depending on the type of splint, different demands are made on design, material and strategy of adjustment. Many different natural and synthetic materials are available for orthopaedic constructions. Because of its good adjustment options, the use of low temperature thermoplastic is steadily increasing. This contribution presents an overview of our currently used splints, new technical developments in our experience with more than 200 patients with obstetrical brachial plexus palsy. We present our experience with the most common splints for the use in fixation after birth-related brachial plexus surgery, subscapularis release, trapezius muscle transfer and functional improvement of hands with a lack of wrist extension.

Constraint-induced movement therapy for children with obstetric brachial plexus palsy: two single-case series.

The objective of this pilot study was to investigate the feasibility of constraint-induced movement therapy (CIMT) in children with obstetric brachial plexus palsy and receive preliminary information about functional improvements. Two patients (age 12 years) with obstetric brachial plexus palsy were included for a 126-h home-based CIMT intervention (3 and 4.5 weeks) and weekly monitored with the Melbourne Assessment of Unilateral Upper Limb function and the Nine-hole Peg Test. The Assisted Hand Assessment was performed 3 weeks before the beginning of intervention, preintervention, postintervention, and at 3 weeks follow-up (ABA single-case design). Tests were analyzed descriptively, visually, and where possible, using a time series analysis with C statistic. Results revealed changes of arm function in both patients between preintervention and follow-up test as follows: Assisted Hand Assessment from 85 to 92% in patient A and 80 to 89% in patient B, in the Melbourne Assessment of Unilateral Upper Limb function from 87 to 90% (C=0.578, z=1.876, P<0.05) in patient A and 72 to 80% (C=0.827, z=2.68, P<0.005) in patient B. There was no improvement in the Nine-hole Peg Test in both patients. Improvements as a result of CIMT found in this pilot study may not be considered substantial. However, they justify further research as some findings indicate relationship to the CIMT intervention in the 'B' phase. To enhance motivation and to plan a controlled, randomized clinical trial, child-friendly applications of the CIMT concept and adequate measures to monitor compliance are being discussed.

Shoulder external rotation tendon transfers for brachial plexus birth palsy.

Children with brachial plexus birth palsy may have permanent loss of shoulder external rotation strength. This impairment may result to a difficulty in reaching the face and head with the affected hand for grooming activities, and in reaching overhead for participation in sports or work-related tasks. In addition, the contracture that results from unopposed internal rotation may further restrict range of motion and cause glenohumeral joint deformity and subluxation.A combination of muscle release and transfers reliably improves the child's ability to position the hand, and may halt the development of joint deformity. Postoperative rehabilitation is necessary to maximize the strength and range of motion obtained from this operation.