Obstetric brachial plexus lesions and central developmental disability

Virtual Reality for Upper Limb Rehabilitation in Patients With Obstetric Brachial Palsy: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Obstetric brachial palsy (OBP) is a pathology caused by complications during childbirth because of cervical spine elongation, affecting the motor and sensory innervation of the upper limbs. The most common lesion occurs on the C5 and C6 nerve branches, known as Erb-Duchenne palsy. The least common lesion is when all nerve roots are affected (C5-T1), which has the worst prognosis. Virtual reality (VR) is commonly used in neurological rehabilitation for the evaluation and treatment of physical deficits.

OBJECTIVE

This systematic review aims to assess the efficacy of VR in the rehabilitation of upper limb function in patients with OBP.

METHODS

A search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines in several scientific databases-PubMed, Web of Science, PEDro, Cochrane, MEDLINE, Scopus, and CINAHL-without language or date restrictions and including articles published up to April 2023. The inclusion criteria were established according to the population, intervention, comparison, outcome, and study (PICOS) design framework: children aged <18 years diagnosed with OBP, VR therapy used in addition to conventional therapy or isolated, VR therapy compared with conventional therapy, outcomes related to OBP rehabilitation therapy, and randomized controlled trials (RCTs). The PEDro scale was used to assess the methodological quality of the RCTs, and the Cochrane Collaboration tool was used to assess the risk of bias. The Review Manager statistical software (version 5.4; The Cochrane Collaboration) was used to conduct the meta-analysis. The results were synthesized through information extraction and presented in tables and forest plots.

RESULTS

In total, 5 RCTs were included in this systematic review, with 3 (60%) providing information for the meta-analysis. A total of 138 participants were analyzed. All the studies used semi-immersive or nonimmersive VR systems. The statistical analysis showed no favorable results for all outcomes except for the hand-to-mouth subtest of the Mallet scoring system (functional activity; standardized mean difference -0.97, 95% CI -1.67 to -0.27; P=.007).

CONCLUSIONS

The evidence for the use of VR therapy for upper limb rehabilitation outcomes in patients with OBP was insufficient to support its efficacy and strongly recommend its use. Nevertheless, scientific literature supports the use of VR technologies for rehabilitation as it provides several advantages, such as enhancing the patient's motivation, providing direct feedback, and focusing the patient's attention during the intervention. Thus, the use of VR for upper limb rehabilitation in patients with OBP is still in its first stages. Small sample sizes; limited long-term analysis; lack of testing of different doses; and absence of International Classification of Functioning, Disability, and Health-related outcomes were present in the included RCTs, so further research is needed to fully understand the potential of VR technologies as a therapeutic approach for patients with OBP.

TRIAL REGISTRATION

PROSPERO CRD42022314264; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=314264.

Promoting Recovery Following Birth Brachial Plexus Palsy

Neonatal brachial plexus palsies (NBPP) occur in 1.74 per 1000 live births with 20% to 30% having persistent deficits. Dysfunction can range from mild to severe and is correlated with the number of nerves involved and the degree of injury. In addition, there are several comorbidities and musculoskeletal sequelae that directly impact the overall functional development. This review addresses the nonsurgical and surgical management options and provides guidance for pediatricians on monitoring and when to refer for specialty care.

Comorbidities in Infants and Children with Neonatal Brachial Plexus Palsy: A Scoping Review to Inform Multisystem Screening

AIMS

The scoping review was undertaken to explore comorbidities in infants and children with neonatal brachial plexus palsy (NBPP). The purpose of the review was to inform physical and occupational therapy screening of multiple body systems during the examination of children with NBPP.

METHODS

EBSCO Discovery and EMBASE electronic databases were searched for reports published between January 1996 and September 2021 describing comorbidities in children with NBPP between birth and 18 years. Key data pertaining to comorbidity prevalence, risk factors, clinical features, and associated outcomes were extracted and charted by one researcher and confirmed by a second researcher.

RESULTS

Thirty-six articles were included in the scoping review. Fourteen comorbidities were identified across the musculoskeletal, neurological, cardiopulmonary, and integumentary systems and the communication domain. The most prevalent comorbidities were clavicle fractures, plagiocephaly, torticollis, high body mass index, and language delays. The least prevalent comorbidity was facial nerve palsy.

CONCLUSIONS

Physical and occupational therapists can use knowledge of comorbidities in infants and children with NBPP for multisystem screening during the examination. A thorough history can identify risk factors for comorbidities. Detection of comorbidities during screening allows for timely specialty referrals to optimize care.

Early Spontaneous Movements and Upper Extremity Movement Score in Infants With all Narakas Types of Obstetric Brachial Plexus Palsy

BACKGROUND

Obstetric brachial plexus palsy (OBPP) is a birth injury that affects upper extremity performance. However, some children with OBPP might have central nervous system disorder or developmental disabilities. This study aimed to investigate (1) the early spontaneous movements using General Movements Assessment (GMA) in infants with OBPP according to the Narakas classification, (2) the differences from typical infants, and (3) the relationship between the GMA and the affected upper extremity movements score.

METHODS

Fifty-six infants with OBPP (39 females; median gestational age 40 weeks, range = 34 to 42) and 50 typical infants (20 females; median gestational age 38 weeks, range = 37 to 41) were assessed at age three to five months using the GMA, which is a determined Motor Optimality Score (MOS) for fidgety movements and concurrent motor repertoire, and using the Active Movement Scale (AMS) for affected upper extremity movements.

RESULTS

There were no differences in MOS and its subcategories between Narakas types in infants with OBPP (P > 0.05); however, infants with OBPP had a higher degree of aberrant fidgety movements and a lower score in MOS and its subcategories than typical infants (P < 0.05). There was no relationship between AMS scores, and MOS and its subcategories.

CONCLUSIONS

Infants with OBPP, except Narakas type I, might have an increased risk of central nervous disorder and developmental problems in addition to peripheral nerve injury. Each test, GMA and AMS, contributes to the identification of their own specific risk in these infants.

How brachial plexus birth palsy affects motor development and upper extremity skill quality?

PURPOSE

This study aimed to investigate the gross motor functions including head control, midline crossing, and rolling, and the relationship between these developmental skills and upper extremity skill quality in children with neonatal brachial plexus palsy (NBPP).

METHODS

A total of 106 children with NBPP, aged 10-18 months, were included in this study. Injury severity was determined with the Narakas Classification. The gross motor function measurement lying and rolling sub-scale was used to evaluate gross motor functions including head control, midline crossing, and rolling, while the Quality of Upper Extremity Skills Test was applied to assess the upper extremity skill quality. The assessments were performed only once during routine physiotherapy controls.

RESULTS

As the severity of injury increased, developmental skill capacity decreased and upper extremity skill quality deteriorated (ps = 0.0001). There was a strong positive correlation between these developmental skills and upper extremity skill quality (ps = 0.0001).

CONCLUSION

Developmental skills are affected by NBPP. Rehabilitation programs aimed at increasing the quality of upper extremity skills should be included in neurodevelopmental treatment approaches.

The Relationship between Trunk Control and Upper Extremity Function in Children with Obstetric Brachial Plexus Palsy

PURPOSE

This study aimed to assess sitting skills and trunk control in children with obstetric brachial plexus palsy (OBPP) and investigate the effect of these skills on upper extremity function.

METHODS

A total of 106 children with OBPP aged 10-18 months were included in this study. Injury severity was determined with Narakas Classification. The Gross Motor Function Measurement Sitting Sub-scale was used to assess sitting skills, while the Sitting Assessment Scale was used to evaluate the trunk control. The upper extremity functions were assessed with using the Active Movement Scale and the Modified Mallet Score.

RESULTS

As the severity of injury increased, sitting skills and trunk control values decreased (p = .0001). In addition, upper extremity function decreased with the decreasing sitting skills and trunk control (p = .0001).

CONCLUSION

Rehabilitation approaches should involve approaches that aim to increase trunk control in addition to programs targeting the extremity function in children with OBPP.

Assessment of Motor Repertoire in 3- to 5-Month-Old Infants With Obstetric Brachial Plexus Lesion

PURPOSE

The aim of this study was to define the movement characteristics and postures of infants with obstetric brachial plexus lesion.

METHODS

The study group included 20 infants with obstetric brachial plexus lesion and a control group of 20 infants with normal neurological outcome, aged 9 to 17 weeks postterm. Infants were evaluated by global and detailed general movements assessment.

RESULTS

There were no significant differences between the motor optimality scores of the 2 groups. However, there were some differences in terms of concurrent movements and the posture. Infants with obstetric brachial plexus lesion demonstrated more excitement bursts, head rotation, hand-knee contact, rolling, and few finger posture and postural asymmetry, and performed jerky movements when compared with the control group.

CONCLUSIONS

Obstetric brachial plexus lesion did not affect the quality of fidgety movements of the infants but leads to compensatory movements in concurrent movements on the unaffected sides.

Network-centric medicine for peripheral nerve injury: Treating the whole to boost endogenous mechanisms of neuroprotection and regeneration

Peripheral nerve injuries caused by accidents may lead to paralysis, sensory disturbances, anaesthesia, and lack of autonomic functions. Functional recovery after disconnection of the motoneuronal soma from target tissue with proximal rupture of axons is determined by several factors: motoneuronal soma viability, proper axonal sprouting across inhibitory zones and elongation toward specific muscle, effective synapse contact rebuilding, and prevention of muscle atrophy. Therapies, such as adjuvant drugs with pleiotropic effects, that promote functional recovery after peripheral nerve injury are needed. Toward this aim, we designed a drug discovery workflow based on a network-centric molecular vision using unbiased proteomic data and neural artificial computational tools. Our focus is on boosting intrinsic capabilities of neurons for neuroprotection; this is in contrast to the common approach based on suppression of a pathobiological pathway known to be associated with disease condition. Using our workflow, we discovered neuroheal, a combination of two repurposed drugs that promotes motoneuronal soma neuroprotection, is anti-inflammatory, enhances axonal regeneration after axotomy, and reduces muscle atrophy. This drug discovery workflow has thus yielded a therapy that is close to its clinical application.

Sensibility of the Hand in Children With Conservatively or Surgically Treated Upper Neonatal Brachial Plexus Lesion

BACKGROUND

The aim of this study was to assess the sensibility of the hand in children with a neonatal brachial plexus palsy (NBPP) involving the C5 and C6, and to correlate results with dexterity.

METHODS

Fifty children with NBPP (30 after nerve surgery, mean age 9.8 years) and 25 healthy controls (mean age 9.6 years) were investigated. Sensibility was assessed with two-point discrimination and Semmes-Weinstein monofilaments. Dexterity was evaluated with a single item from the Movement Assessment Battery for Children-2. We compared the affected side with the nondominant hand of the control group.

RESULTS

The sensibility in the first and second fingers was significantly diminished in the NBPP for both two-point discrimination (P = 0.005 and P = 0.014, respectively) and monofilament test (P < 0.001). Dexterity was significantly lower in the NBPP group than in control group, corrected for age (P = 0.023). There was a significant difference toward decreasing hand function with decreasing sensibility according to the Semmes-Weinstein test for the thumb (Jonckheere-Terpstra nonparametric trend test, P = 0.036).

CONCLUSIONS

The sensibility of the thumb and index finger in children with an upper plexus lesion (either surgically or conservatively treated) is diminished. The decreased sensibility has a negative impact on hand function. Appreciation of diminished hand function in patients with NBPP involving C5 and C6 is important to optimize treatment.

Fidgety movements - tiny in appearance, but huge in impact

OBJECTIVES

To describe fidgety movements (FMs), i.e., the spontaneous movement pattern that typically occurs at 3-5 months after term age, and discuss its clinical relevance.

SOURCES

A comprehensive literature search was performed using the following databases: MEDLINE/PubMed, CINAHL, The Cochrane Library, Science Direct, PsycINFO, and EMBASE. The search strategy included the MeSH terms and search strings ('fidgety movement*') OR [('general movement*') AND ('three month*') OR ('3 month*')], as well as studies published on the General Movements Trust website (www.general-movements-trust.info).

SUMMARY OF THE DATA

Virtually all infants develop normally if FMs are present and normal, even if their brain ultrasound findings and/or clinical histories indicate a disposition to later neurological deficits. Conversely, almost all infants who never develop FMs have a high risk for neurological deficits such as cerebral palsy, and for genetic disorders with a late onset. If FMs are normal but concurrent postural patterns are not age-adequate or the overall movement character is monotonous, cognitive and/or language skills at school age will be suboptimal. Abnormal FMs are unspecific and have a low predictive power, but occur exceedingly in infants later diagnosed with autism.

CONCLUSIONS

Abnormal, absent, or sporadic FMs indicate an increased risk for later neurological dysfunction, whereas normal FMs are highly predictive of normal development, especially if they co-occur with other smooth and fluent movements. Early recognition of neurological signs facilitates early intervention. It is important to re-assure parents of infants with clinical risk factors that the neurological outcome will be adequate if FMs develop normally.

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.

Pharmacologic rescue of motor and sensory function by the neuroprotective compound P7C3 following neonatal nerve injury

Nerve injuries cause pain, paralysis and numbness that can lead to major disability, and newborns often sustain nerve injuries during delivery that result in lifelong impairment. Without a pharmacologic agent to enhance functional recovery from these injuries, clinicians rely solely on surgery and rehabilitation to treat patients. Unfortunately, patient outcomes remain poor despite application of the most advanced microsurgical and rehabilitative techniques. We hypothesized that the detrimental effects of traumatic neonatal nerve injury could be mitigated with pharmacologic neuroprotection, and tested whether the novel neuroprotective agent P7C3 would block peripheral neuron cell death and enhance functional recovery in a rat neonatal nerve injury model. Administration of P7C3 after sciatic nerve crush injury doubled motor and sensory neuron survival, and also promoted axon regeneration in a dose-dependent manner. Treatment with P7C3 also enhanced behavioral and muscle functional recovery, and reversed pathological mobilization of spinal microglia after injury. Our findings suggest that the P7C3 family of neuroprotective compounds may provide a basis for the development of a new neuroprotective drug to enhance recovery following peripheral nerve injury.

High prevalence of early language delay exists among toddlers with neonatal brachial plexus palsy

AIM

An association of language impairment with neonatal brachial plexus palsy has not been reported in the literature. The current treatment paradigm for neonatal brachial plexus palsy focuses on upper extremity motor recovery with little formal assessment of other aspects of development, such as language. We performed a cross-sectional pilot study to investigate early language delay prevalence in toddlers with neonatal brachial plexus palsy and potential neonatal brachial plexus palsy-related factors involved.

METHOD

Twenty toddlers with neonatal brachial plexus palsy were consecutively recruited (12 males and eight females; mean age, 30 months). Preschool Language Scale Score (4th edition), demographics, and socioeconomic status were collected. Neonatal brachial plexus palsy-related factors such as palsy side, treatment type, Narakas grade, muscle Medical Research Council score, and Raimondi hand score were reported. Student t test, chi-square test, or Fisher exact test were applied. Statistical significance level was established at P < 0.05.

RESULTS

Of study participants, 30% had language delay, whereas the prevalence of language delay in the population with normal development in this age range was approximately 5-15%.

INTERPRETATION

We observed high language delay prevalence among toddlers with neonatal brachial plexus palsy. Although our subject sample is small, our findings warrant further study of this phenomenon. Early identification and timely intervention based on type of language impairment may be critical for improving communication outcome in this population.

Psychometric properties of outcome measures for children and adolescents with brachial plexus birth palsy: a systematic review

AIM

The aim of this review was to evaluate the psychometric properties of outcome measures used to quantify upper limb function in children and adolescents with brachial plexus birth palsy (BPBP).

METHOD

Eleven electronic databases were searched to identify studies on the effects of conservative management to improve upper limb function in young people with BPBP. Outcome measures used in these studies were extracted and used in a subsequent search to identify studies that evaluated the psychometric properties of these measures. The methodological quality of these studies was rated using a standardized critical appraisal tool.

RESULTS

Thirty-three outcome measures and 12 psychometric studies were identified. Nine outcome measures had some psychometric evidence, which was variable in quality. The outcome measures which seem to have the most robust psychometric properties include the Active Movement Scale, Assisting Hand Assessment, Pediatric Evaluation of Disability Index, and the Pediatric Outcomes Data Collection Instrument.

INTERPRETATION

Further research is required to determine the psychometric properties of outcome measures used for children and adolescents with BPBP. Caution is required when interpreting the results of commonly used outcome measures in this population owing to their relatively unknown psychometric properties.