Is mirror therapy combined with a routine physiotherapy protocol effective for children with obstetrical upper brachial plexus palsy?

STUDY DESIGN: Randomized controlled study. INTRODUCTION: Mirror therapy is a rehabilitation strategy based on the repeated use of the mirror illusion and also one of the treatment choice of brachial plexus injuries. PURPOSE: We aimed to determine the effects of mirror therapy combined with a routine rehabilitation program on upper limb motor function in children with obstetric brachial plexus injury. METHODS: Twenty children with obstetric brachial palsy were included in this study. They were randomly allocated to either control (n = 10) or mirror therapy (n = 10) group. The following clinical tools were used to assess the upper extremity function: Active Movement Scale (AMS), Modified Mallet Scale (MMS), Hand Grip Strength (HGS) Test, Finger Grip Strength (FGSM) Test, Box and Block Test (BBT), Nine Hole Peg Test (9-HPT), and goniometric measurement. Both groups received the same routine physiotherapy program for 8 weeks. The study group underwent mirror therapy in addition to the rehabilitation program. RESULTS: The mean age of the study population was 11.35 ± 4.12 years. There was no change in the goniometric values, AMS and MMS scores after the treatment in both groups (p > 0.05), except for the improvement of the wrist extension in the study group (p < 0.05). There was an increase in both HGS and FGS scores in the study group. Only FGS scores improved in the control group after the intervention (p < 0.05). 9-HPT and BBT scores improved in both groups (p < 0.05). All other parameters tested were comparable between the two groups after the treatment. CONCLUSIONS: The results of this study did not show any additional benefits of mirror therapy combined with a rehabilitation protocol compared to routine physiotherapy treatment, but was not adequately powered to do so.

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.

[Physiotherapy applied to the upper extremity in 0 to 10-year-old children with obstetric brachial palsy: a systematic review]. / Fisioterapia aplicada en la extremidad superior a niños de 0 a 10 años con parálisis braquial obstétrica: revisión sistemática.

INTRODUCTION: Obstetric brachial palsy is involved with affected upper limb, resulting in permanent structural and function sequelae that limit the motion articular range and reduce independence in daily activities, as well as the children participation in their natural environment. AIM: To describe the physiotherapy treatments currently used to increase the affected upper limb functionality in children from 0 to 10 years diagnosed with obstetric brachial palsy. PATIENTS AND METHODS: A bibliographic search of published studies between 2009 and 2018 was carried out in the PubMed, PEDro, ScienceDirect and The Cochrane Library databases. RESULTS: After applying the inclusion/exclusion criteria, ten studies were obtained with favorable results for the affected upper limb functionality and bone mineralization density, regardless of the technique of choice used during the intervention. The used physiotherapy programs in the different studies such as Constraint Induced movement therapy, kinesiotape, electrotherapy, virtual reality and use of splints or orthotics were analyzed. CONCLUSION: All the described techniques suggest favorable results for the affected upper limb functionality in obstetric brachial palsy from 0 to 10 years.

TITLE: Fisioterapia aplicada en la extremidad superior a niños de 0 a 10 años con parálisis braquial obstétrica: revisión sistemática.Introducción. La parálisis braquial obstétrica cursa con afectación del miembro superior y da lugar a secuelas estructurales y de la función permanentes que limitan el rango articular de movimiento y reducen la independencia en las actividades cotidianas, así como la participación del niño dentro de su entorno natural. Objetivo. Describir los tratamientos de fisioterapia empleados en la actualidad para incrementar la funcionalidad de la extremidad superior afectada en niños de 0 a 10 años diagnosticados de parálisis braquial obstétrica. Pacientes y métodos. Se realizó una búsqueda bibliográfica de los trabajos publicados entre 2009 y 2018 en las bases de datos PubMed, PEDro, ScienceDirect y Cochrane Library. Resultados. Tras aplicar los criterios de inclusión/exclusión, se obtuvieron diez estudios con resultados favorables para la funcionalidad de la extremidad superior afectada y la densidad de mineralización ósea, independientemente de la técnica de elección utilizada durante la intervención. Se analizaron los programas de fisioterapia empleados en los diferentes estudios, como la terapia de movimiento inducido por restricción, el kinesiotape, la electroterapia, la realidad virtual y el uso de férulas u ortesis. Conclusión. Todas las técnicas descritas sugieren resultados favorables para la funcionalidad del miembro superior en niños de 0 a 10 años con parálisis braquial obstétrica.

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.

Outcomes after occupational therapy intervention for traumatic brachial plexus injury: A prospective longitudinal cohort study.

STUDY DESIGN: Prospective longitudinal cohort study. INTRODUCTION: Traumatic brachial plexus injuries (BPIs) can be devastating and negatively impact daily function and quality of life. Occupational therapists play an important role in rehabilitation; however, studies identifying outcomes are lacking. PURPOSE: This study aims to describe outcomes including motor recovery, upper limb function, participation, pain, and quality of life for people receiving occupational therapy intervention. METHODS: A convenience sample of English-speaking adults (n = 30) with a traumatic BPI, attending the clinic between December 1, 2014, to November 30, 2016, participated. Participants received occupational therapy focusing on sensorimotor retraining and activity-based rehabilitation. Data on active range of motion (goniometry), strength (Medical Research Council (MRC)), upper-limb function (UEFI15, QuickDASH), participation (PSFS), pain (Brief Pain Inventory), and quality of life (EQ-5D-3L) were collected at baseline, 3, 6, 9, and 12 months. RESULTS: Elbow flexion strength showed significant improvement at all time-points, average increase 2.17 (MRC) (95% confidence interval: 1.29-3.04; P < .001) and mean final MRC grading 3.86 (standard error: 0.44). Significant improvements at 12 months were seen in: shoulder abduction strength and range, flexion strength and range, external rotation range; elbow extension strength and flexion range; thumb flexion and extension strength. Upper limb function (QuickDASH) showed significant improvement (mean change = 18.85; 95% confidence interval: 4.12-33.59; P = .02). Forearm protonation range and finger flexion strength were significantly worse. Remaining outcomes did not show significant improvement. CONCLUSIONS: Occupational therapy with surgical intervention can improve strength, range, and upper limb function with people following traumatic BPI. Further investigations into impact on participation, pain, and quality of life are required.

Patient Perception after Traumatic Brachial Plexus Injury - A Qualitative Case Report.

STUDY DESIGN: This is a qualitative case study. INTRODUCTION: Considering individual patient's perception is an important aspect of rehabilitation according to International Classification of Functioning model (Geneva, 2002). PURPOSE OF STUDY: The report highlights the importance of patient education and considering individual's perception to achieve rehabilitation outcomes. METHOD: A written informed consent for case report was given by a 24-year-old male, a mass media graduate student diagnosed with global brachial plexus injury. Detailed evaluation by a senior therapist was conducted in a tertiary government hospital using the following tools: RESULT: Patient education and rehabilitation led to signs of clinical improvement at the end of 5 months. In spite of this clinical signs of recovery, patient showed lack of satisfaction in terms of his appearance and body image. DISCUSSION: As employment and social life determined our patient's satisfaction level, a negative impact was seen on functional recovery. CONCLUSION: Considering an individual's perception regarding the condition in terms of their contextual and personal factors is an important aspect of rehabilitation according to International Classification of Functioning model (Geneva, 2002).

Traumatic brachial plexus injury rehabilitation using neuromuscular electrical muscle stimulation in a polytrauma patient.

We report a 28-year-old man admitted postmotorcycle versus car in September 2017. The patient sustained multiple injuries in both the upper and lower limbs. He sustained a complex brachial plexus injury on his left side and was transferred immediately to Stanmore Hospital to undergo specialist surgery (supraclavicular brachial plexus exploration and neurolysis) to repair his brachial plexus injury. The patient was transferred back to the specialist trauma ward for additional surgeries for his subsequent injuries. Due to the complexity of the injury and surgery the patient was not able to start rehabilitation until six weeks post operation, at which point he was referred to outpatient physiotherapy. Prior to this his left upper limb was in a sling but was instructed to move it as able. The patient commenced his comprehensive physiotherapy programme in January 2018.

Scapular Stabilization Limits Glenohumeral Stretching in Children With Brachial Plexus Injuries.

PURPOSE: To quantify the effects of scapular stabilization on scapulothoracic and glenohumeral (GH) stretching. METHODS: Motion capture data during external rotation and abduction with and without scapular stabilization were collected and analyzed for 26 children with brachial plexus birth palsy. These positions were performed by an experienced occupational therapist and by the child's caretaker. Scapulothoracic and GH joint angular displacements were compared between stretches with no stabilization, stabilization performed by the therapist, and stabilization performed by the caretaker. The relationship between the age and ability of the therapist and caretaker to perform the stretches with scapular stabilization was also assessed. RESULTS: During external rotation there were no significant differences in either the scapulothoracic or GH joint during stabilization by either the therapist or the caretaker. During abduction, both scapulothoracic and GH joint angular displacements were statistically different. Scapulothoracic upward rotation angular displacement significantly decreased with scapular stabilization by the therapist and caretaker. Glenohumeral elevation angular displacement significantly decreased with scapular stabilization performed by the therapist and caretaker. There were only weak correlations between age and the differences in scapulothoracic and GH joint angular displacement performed by both the therapist and the caretaker. CONCLUSIONS: The findings of this study indicate that scapular stabilization may be detrimental to passive stretching of the GH joint in children, as demonstrated by a reduced stretch. Based on the findings of this study, we have changed our practice to recommend passive stretches without scapular stabilization for children aged 5 years and older with brachial plexus birth palsy. In infants and children aged less than 5 years, we now recommend stretching with and without scapular stabilization until the effect of scapular stabilization is objectively assessed in these age groups. LEVEL OF EVIDENCE/TYPE OF STUDY: Therapeutic IV.

Late onset of dropped head syndrome following mantle radiation therapy for Hodgkin lymphoma.

Dropped head syndrome (DHS) is a rare condition, characterised by weakness of the cervical paraspinal muscles with sagging of the head. It is usually seen in association with neurological disorders and rarely can follow radiotherapy. We report a case of a 54-year-old man survivor of Hodgkin lymphoma (HL), who developed DHS 28 years after radiotherapy. He was referred to our department due to progressive weakness and atrophy of cervical paraspinal and shoulder girdle musculature. Physical and neurophysiological examination, electromyography and MRI confirmed the diagnosis of DHS. In the following years, there was no progression of symptoms.

Robotic rehabilitation training with a newly developed upper limb single-joint Hybrid Assistive Limb (HAL-SJ) for elbow flexor reconstruction after brachial plexus injury: A report of two cases.

This study aimed to evaluate the effectiveness and safety of using the upper limb single-joint Hybrid Assistive Limb (upper limb HAL-SJ) during elbow flexion training following elbow flexor reconstruction for brachial plexus injury (BPI). We present the cases of two patients in whom the upper limb HAL-SJ was implemented 5 and 7 months postoperatively following elbow flexor reconstruction for BPI. They underwent elbow flexor reconstruction with intercostal nerve crossing-to-musculocutaneous nerve (ICN-MCN crossing) after BPI. Postoperative training using the upper limb HAL-SJ was started from the Medical Research Council (MRC) grade 1 elbow flexion power to MRC grade 3 once every week or every 2 weeks. Both patients could implement elbow training using the upper limb HAL-SJ even in MRC grade 1 of their elbow flexion power. Training with the upper limb HAL-SJ was performed safely and effectively in two patients with elbow flexor reconstruction with ICN crossing after BPI.

A comparative study of rehabilitation therapy in traumatic upper limb peripheral nerve injuries.

INTRODUCTION: Lower motor neurons are the only neurons of the central nervous system (CNS) with the ability to regenerate without any intervention after an axotomy. AIM: This present study was conducted to analyze clinical and electrophysiological parameters in four groups of upper limb peripheral neuropathies, before and after treatment, comparing the results obtained after three cures of complex rehabilitation therapy. MATERIALS AND METHODS: We selected a number of 107 patients (66 women and 41 men) aged between 29 and 77 years (mean age = 49.6). Clinical (muscular strength, sensitivity) and electrophysiological parameters (accommodation coefficient α, nerve conduction velocity) were analyzed. All patients received 3 comprehensive treatment cures, each cure of 14 days and a rest period of 3 months between the cures. RESULTS: From the total of 107 patients included in the study, 52 were diagnosed with brachial plexus palsy, 27 with radial nerve palsy, 18 with median nerve palsy and 10 with ulnar nerve palsy. We did not observe a statistically significant difference between the mean age of males (47.2) and females (51.2) (p = 0.07), but peripheral neuropathies were more common in young males. At the end of the rehabilitation treatment all patients achieved better outcomes in muscle strength, sensitivity, adjustment coefficient α and nerve conduction velocity (p < 0.001).CONCLUSIONThe intervention of a physical therapy program in patients with peripheral neuropathies provided significantly better outcomes in clinical and electrophysiological parameters. Our rehabilitation protocol can be considered an alternative in order to stimulate and accelerate the nerve regeneration process.

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.

Effects of elastic therapeutic taping on motor function in children with motor impairments: a systematic review.

BACKGROUND: The elastic therapeutic taping has been considered a promising resource for disabled children. OBJECTIVE: To systematically review the evidence of the effects of elastic therapeutic taping on motor function in children with motor impairments. METHOD: Three independent evaluators conducted searches in electronic databases (MEDLINE/PubMed, Scopus, LILACS, BIREME/BVS, Science Direct, SciELO, and PEDro). Clinical studies design, published until 2016, involving elastic therapeutic taping and children aged 0-12 years with motor impairments were included. The variables considered were the methodological aspects (study design, participants, outcome measurements, and experimental conditions); results presented in the studies, and also the methodological quality of studies. RESULTS: Final selection was composed by 12 manuscripts (five randomized controlled trials), published in the last 10 years. Among them, cerebral palsy (CP) was the most recurrent disorder (n = 7), followed by congenital muscular torticollis (n = 2) and brachial plexus palsy (n = 2). Positive results were associated with taping application: improvement in the upper limb function, gross motor skills, postural control, muscular balance, and performance in the dynamics functional and daily activities. LIMITATIONS: Lower quality of the studies, clinical and population heterogeneity existed across studies. CONCLUSIONS: The elastic therapeutic taping has been shown to be a promising adjunct resource to the conventional rehabilitation in children with motor impairments. However, high methodological studies about its efficacy in this population are already scarce. Implications for Rehabilitation Elastic therapeutic taping has been shown to be a promising adjunct resource to the conventional rehabilitation in disabled children. Clinical trials have indicated improvement in the postural control and functional activities with both, upper and lower limbs, and increase in the functional independency resulting from the taping use. Randomized control trials and well-established protocols are needed to increase the confidence in applying elastic therapeutic taping to specific clinical conditions.

Efficacy of 3 therapeutic taping configurations for children with brachial plexus birth palsy.

STUDY DESIGN: Cross-sectional clinical measurement study. INTRODUCTION: Scapular winging is a frequent complaint among children with brachial plexus birth palsy (BPBP). Therapeutic taping for scapular stabilization has been reported to decrease scapular winging. PURPOSE OF THE STUDY: This study aimed to determine which therapeutic taping construct was most effective for children with BPBP. METHODS: Twenty-eight children with BPBP participated in motion capture assessment with 4 taping conditions: (1) no tape, (2) facilitation of rhomboid major and rhomboid minor, (3) facilitation of middle and lower trapezius, and (4) facilitation of rhomboid major, rhomboid minor, and middle and lower trapezius (combination of both 2 and 3, referred to as combined taping). The participants held their arms in 4 positions: (1) neutral with arms by their sides, (2) hand to mouth, (3) hand to belly, and (4) maximum crossbody adduction (CBA). The scapulothoracic, glenohumeral and humerothoracic (HT) joint angles and joint angular displacements were compared using multivariate analyses of variance with Bonferroni corrections. RESULTS: Scapular winging was significantly decreased in both the trapezius and combined taping conditions in all positions compared with no tape. Rhomboids taping had no effect. Combined taping reduced HT CBA in the CBA position. CONCLUSIONS: Rhomboid taping cannot be recommended for treatment of children with BPBP. Both trapezius and combined taping approaches reduced scapular winging, but HT CBA was limited with combined taping. Therefore, therapeutic taping of middle and lower trapezius was the most effective configuration for scapular stabilization in children with BPBP. Resting posture improved, but performance of the positions was not significantly improved. LEVEL OF EVIDENCE: Level II.

Participation restrictions among adolescents and adults with neonatal brachial plexus palsy: the patient perspective.

PURPOSE: To examine the impact of neonatal brachial plexus palsy (NBPP) on societal participation of adolescents and adults. METHODS: This cross-sectional study was conducted among patients with NBPP, aged ≥16 years, who had visited our NBPP clinic. Patients completed questions on the influence of NBPP on their choices regarding education/work and their work-performance, the Impact on Participation/Autonomy questionnaire and the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). In addition, health-related quality of life (HRQoL) was assessed. RESULTS: Seventy-five patients participated (median age 20, inter quartile range 17-27). Twenty were full-time students, 28 students with a job, 21 employed, two unemployed, and four work-disabled. Sixty-six patients had had a job at some stage. Patients' overall HRQoL was comparable to the general population. 27/75 patients reported that NBPP had affected their choices regarding education and 26/75 those regarding work. 33/66 reported impact on their work performance. On the Impact on Participation/Autonomy questionnaire, 80% (49/61) reported restrictions in the work-and-education domain, 74% in social-relations and 67% in autonomy-outdoors. 37/61 reported participation restrictions on the USER-P. CONCLUSIONS: Although their overall HRQoL was not impaired, a substantial proportion of adolescent/adult patients reported that NBPP had an impact on choices regarding education and profession, as well as on work-performance. Restrictions in participation, especially in work and education were also reported. Guiding patients in making choices on education and work at an early stage and providing tailored physical as well as psychosocial care may prevent or address restrictions, which may improve participation. Implications for Rehabilitation Adolescent and adult patients with neonatal brachial plexus palsy perceive restrictions in societal participation, especially regarding the work-and-education domain. All patients with neonatal brachial plexus palsy may perceive restrictions in societal participation regardless of lesion severity, treatment history and side of the lesion. Adolescents and adults with neonatal brachial plexus palsy report that their choices regarding education and work, as well as their work-performance are influenced by their neonatal brachial plexus palsy. Patients with neonatal brachial plexus palsy should be followed throughout their life in order to provide them with appropriate information and treatment when health- or participation-related issues arise. Rehabilitation treatment is the best option to address all of the aforementioned issues, as surgical options in adolescents and adults are limited.

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.

A Review of Brachial Plexus Birth Palsy: Injury and Rehabilitation.

Brachial plexus injuries during the birthing process can leave infants with upper extremity deficits corresponding to the location of the lesion within the complex plexus anatomy. Manifestations can range from mild injuries with complete resolution to severe and permanent disability. Overall, patients have a high rate of spontaneous recovery (66-92%).1,2 Initially, all lesions are managed with passive range motion and observation. Prevention and/or correction of contractures with occupational therapy and serial splinting/casting along with encouraging normal development are the main goals of non-operative treatment. Surgical intervention may be war- ranted, depending on functional recovery. [Full article available at http://rimed.org/rimedicaljournal-2017-11.asp].

Plexopatía braquial por herpes zóster. Reporte de un caso / Herpes zoster brachial plexopathy. A case report

La plexopatía por herpes zoster es una enfermedad no común y pocas veces descrita en la literatura. Se presenta el caso de una mujer de 74 años con alteración motora, sensitiva y dolor neuropático en el miembro superior izquierdo por lesión axonal del cordón medial del plexo braquial secundario a herpes zoster. El compromiso axonal es poco frecuente, y tiene una presentación prolongada en el tiempo y un periodo de recuperación largo. Se realiza intervención a través de un equipo interdisciplinario, con el fin de disminuir y prevenir los daños ocasionados, permitiéndole a la paciente obtener el mayor grado de independencia funcional y control de su sintomatología (AU)

Herpes zoster plexopathy is an uncommon entity and few reports have been published in the literature. We report the case of a 74-year-old woman with neuropathic pain and motor and sensory and involvement in the left upper limb due to axonal injury of the medial cord of the brachial plexus secondary to herpes zoster. Axonal involvement is very unusual and has a prolonged presentation over time with a slow recovery period. Management was provided through an interdisciplinary team to reduce and prevent injury, allowing the patient to obtain the highest possible degree of functional independence and symptom control (AU)