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Mendiratta D, Levidy MF, Chu A, McGrath A. Rehabilitation protocols in neonates undergoing primary nerve surgery for upper brachial plexus palsy: A scoping review. Microsurgery 2024; 44:e31154. [PMID: 38376241 DOI: 10.1002/micr.31154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/24/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION Surgical management is recommended in patients with severe neonatal brachial plexus palsy (NBPP) within the first 6 months of age to regain best possible function. Rehabilitation post-surgery remains relatively unexplored. This is a scoping review that explores, which rehabilitation modalities exist and how they vary for different microsurgical approaches in NBPP. MATERIALS AND METHODS A systematic search was conducted to include articles about upper trunk obstetric brachial plexus nerve microsurgery in pediatric patients that made mention of rehabilitation protocols. The aims of rehabilitation modalities varied and were grouped: "passive" movement to prevent joint contracture or stiffness, "active" or task-oriented movement to improve motor function, or "providing initial motor recovery". Surgical approach was described as either exploration of the brachial plexus (EBP) or nerve transfer without root exploration (NTwoRE). Technique was categorized into transfers and non-transfers. RESULTS Thirty-six full-text articles were included. Initiation of rehabilitation was 22.26 days post-surgery. Twenty-eight studies were EBP, and six were NTwoRE. Of studies classifiable by aims, nine were "passive", nine were "active", and five were "providing initial motor recovery". Only 27.7% of EBP studies mentioned active therapy, while 75.0% of NTwoRE studies mentioned active therapy. The average age of patients in the EBP procedure category was 7.70 months, and NTwoRE was 17.76 months. Within transfers, the spinal accessory to suprascapular group was more likely to describe an active shoulder exercise therapy, whereas contralateral C7 group was more likely to describe "initial motor recovery", especially through the use of electrostimulation. All articles on electrostimulation recommended 15-20-minute daily treatment. CONCLUSION Information on rehabilitation is limited post-nerve surgery in NBPP. However, when mentioned, the aims of these therapies vary with respect to surgical approach and technique. The type of therapy to employ may be a multifaceted decision, involving factors such as patient age, initial deformity, and goals of the care team.
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Affiliation(s)
- Dhruv Mendiratta
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Michael F Levidy
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Alice Chu
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Aleksandra McGrath
- Department of Clinical Sciences, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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Sicari M, Longhi M, D'Angelo G, Boetto V, Lavorato A, Cocchini L, Beatrici M, Battiston B, Garbossa D, Massazza G, Titolo P. Modified constraint induced movement therapy in children with obstetric brachial plexus palsy: a systematic review. Eur J Phys Rehabil Med 2022; 58:43-50. [PMID: 34747579 PMCID: PMC9980490 DOI: 10.23736/s1973-9087.21.06886-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Obstetric brachial plexus palsy (OBPP) is a flaccid paralysis occurring in the upper limb during birth. The OBPP includes mild lesions with complete spontaneous recovery and severe injuries with no regain of arm function. Among the most promising rehabilitation treatments aimed at improving upper extremity motor activities in individuals with neurological dysfunctions, there is the modified constraint-induced movement therapy (mCIMT). The aim of this systematic review is to assess and synthesize the critical aspects of the use of mCIMT in children with OBPP. EVIDENCE ACQUISITION This systematic review has been carried out according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis). A comprehensive search of the literature was conducted using PubMed, MEDLINE and Evidence Based Medicine Reviews, databases. We enclosed experimental and original articles, case reports and book chapters. Four articles were finally included. EVIDENCE SYNTHESIS One case report tested the feasibility of mCIMT to encourage use of the affected arm in a child with Erb-Duchenne palsy and documented the clinical changes observed. A case series had the purpose to determine if mCIMT in combination with botulinum toxin (BTX-A) improved arm function in 2 children with OBPP. A cohort study compared the use of mCIMT in 19 OBPP and 18 unilateral Cerebral Palsy. A prospective single-blind RCT described mCIMT versus conventional therapy in a group of 39 children with OBPP. CONCLUSIONS This systematic review on the use of mCIMT in children with OBPP shows that there is unanimous agreement that a program should last 2 weeks at least. However, there is no scientific evidence supporting a single common mCIMT protocol in the management of OBPP because of a considerable heterogeneity. Further high methodological studies regarding the application of mCIMT for OBPP and based on larger patients' sample should have the potential to optimize the appropriateness of care provided to infants with OBPP and, therefore, their quality of life.
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Affiliation(s)
- Monica Sicari
- Department of Neurorehabilitation, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Maria Longhi
- Unit of Rehabilitation Medicine, Department of Neuroscience, University Hospital of Modena, Modena, Italy -
| | - Giulia D'Angelo
- Division of Physical Medicine and Rehabilitation, ASLTO3, Turin, Italy
| | - Valentina Boetto
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Andrea Lavorato
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini, " University of Turin, Turin, Italy
| | - Lorella Cocchini
- Department of Neurorehabilitation, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Maurizio Beatrici
- Department of Neurorehabilitation, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Bruno Battiston
- Unit of Hand and Upper Limb Surgery, Department of Orthopedics and Traumatology, Orthopedic and Trauma Center, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Diego Garbossa
- Unit of Neurosurgery, Department of Neuroscience "Rita Levi Montalcini, " University of Turin, Turin, Italy
| | - Giuseppe Massazza
- Division of Physical Medicine and Rehabilitation, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Paolo Titolo
- Unit of Hand and Upper Limb Surgery, Department of Orthopedics and Traumatology, Orthopedic and Trauma Center, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
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Yan D, Vassar R. Neuromuscular electrical stimulation for motor recovery in pediatric neurological conditions: a scoping review. Dev Med Child Neurol 2021; 63:1394-1401. [PMID: 34247385 DOI: 10.1111/dmcn.14974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 12/31/2022]
Abstract
AIM To explore the breadth of pediatric neurological conditions for which neuromuscular electrical stimulation (NMES) has been studied. METHOD Databases (PubMed, Google Scholar, Scopus, and Embase) were searched from 2000 to 2020, using the search terms 'neuromuscular electrical stimulation' OR 'functional electrical stimulation' with at least one of the words 'pediatric OR child OR children OR adolescent', and without the words 'dysphagia OR implanted OR enuresis OR constipation'. Articles focused on adults or individuals with cerebral palsy (CP) were excluded. RESULTS Thirty-five studies met the inclusion criteria, with a total of 353 pediatric participants (293 unique participants; mean age 7y 4mo, range 1wk-38y). NMES was applied in a range of pediatric conditions other than CP, including stroke, spinal cord injury, myelomeningocele, scoliosis, congenital clubfoot, obstetric brachial plexus injury, genetic neuromuscular diseases, and other neuromuscular conditions causing weakness. INTERPRETATION All 35 studies concluded that NMES was well-tolerated and most studies suggested that NMES could augment traditional therapy methods to improve strength. Outcome measurements were heterogeneous. Further research on NMES with larger, randomized studies will help clarify its potential to improve physiology and mobility in pediatric patients with neuromuscular conditions. What this paper adds Neuromuscular electrical stimulation (NMES) appears to be tolerated by pediatric patients. NMES shows potential for augmenting recovery in pediatric patients with a range of rehabilitation needs.
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Affiliation(s)
- Derek Yan
- Winston Churchill High School, Potomac, MD, USA
| | - Rachel Vassar
- Department of Neurology, Division of Pediatric Neurology, University of California San Francisco, San Francisco, CA, USA
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Modified constraint-induced movement therapy during hospitalization in children with perinatal brachial plexus palsy: A randomized controlled trial. J Hand Ther 2021; 33:418-425. [PMID: 32151503 DOI: 10.1016/j.jht.2019.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 09/29/2019] [Accepted: 12/31/2019] [Indexed: 02/03/2023]
Abstract
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.
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Werner JM, Berggren J, Loiselle J, Lee GK. Constraint-induced movement therapy for children with neonatal brachial plexus palsy: a randomized crossover trial. Dev Med Child Neurol 2021; 63:545-551. [PMID: 33219706 DOI: 10.1111/dmcn.14741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Julie M Werner
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Division of Pediatric Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jamie Berggren
- Division of Pediatric Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jennifer Loiselle
- Division of Pediatric Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Gina Kim Lee
- Division of Pediatric Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Gonçalves RV, Araujo RCD, Ferreira VKG. Efeito do treino de alcance combinado com estimulação elétrica em lactentes com paralisia braquial perinatal: estudo experimental de caso único. FISIOTERAPIA E PESQUISA 2021. [DOI: 10.1590/1809-2950/19037028012021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO O objetivo deste estudo foi avaliar o efeito do treino de alcance combinado à estimulação elétrica funcional (FES) na movimentação ativa do membro superior de lactentes com paralisia braquial perinatal (PBP). Trata-se de estudo experimental de caso único do tipo A-B com follow-up. Foram documentados semanalmente dados relativos à função do membro superior (Escala de Movimento Ativo) de dois lactentes, uma menina e um menino de 7 e 10 meses de idade, respectivamente. Após seis avaliações, três vezes por semana, durante duas semanas, na linha de base (A), a intervenção consistiu em aplicar FES Neurodyn® no músculo deltoide em combinação com treino de alcance de objetos, incentivando abdução e flexão anterior de ombro acima de 90°, durante seis semanas, totalizando 15 atendimentos (B). Os lactentes foram reavaliados duas vezes após um período de 15 e 30 dias sem intervenção (follow-up). A pontuação total obtida em cada dia de avaliação foi representada graficamente. Houve boa aceitação da eletroestimulação, sem nenhum efeito colateral. Ambos os lactentes apresentaram melhora da movimentação ativa do membro superior afetado após a intervenção e os ganhos foram mantidos no follow-up, com aumento de 9 e 7 pontos para os lactentes 1 e 2, respectivamente. Seis semanas de intervenção resultaram em mudanças individuais na função do membro superior dos lactentes, principalmente no aumento da amplitude de movimento ativo em flexão e abdução de ombro e flexão de cotovelo. Os resultados deste estudo sugerem o uso de estimulação elétrica como coadjuvante do treino do uso do membro superior afetado de lactentes com PBP.
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Schmieg S, Nguyen JC, Pehnke M, Yum SW, Shah AS. Team Approach: Management of Brachial Plexus Birth Injury. JBJS Rev 2020; 8:e1900200. [PMID: 32618739 DOI: 10.2106/jbjs.rvw.19.00200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Sandra Schmieg
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Meagan Pehnke
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sabrina W Yum
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Apurva S Shah
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Zielinski IM, van Delft R, Voorman JM, Geurts ACH, Steenbergen B, Aarts PBM. The effects of modified constraint-induced movement therapy combined with intensive bimanual training in children with brachial plexus birth injury: a retrospective data base study. Disabil Rehabil 2019; 43:2275-2284. [PMID: 31814455 DOI: 10.1080/09638288.2019.1697381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In children with Brachial Plexus Birth Injury, a non-use of the affected upper limb despite sufficient capacity, is sometimes observed, called developmental disregard. The combination of modified constraint-induced-movement-therapy with bimanual training is frequently applied to overcome developmental disregard in unilateral Cerebral Palsy. In the current study the effects of the combination of modified constraint-induced-movement-therapy with bimanual training are investigated in children with Brachial Plexus Birth Injury in comparison to children with unilateral Cerebral Palsy. We hypothesize that the combination of modified constraint-induced-movement-therapy with bimanual training is effective in Brachial Plexus Birth Injury. METHODS Data of 19 children with Brachial Plexus Birth Injury (Mage: 4.1 years) and 18 with unilateral Cerebral Palsy (Mage: 4.5 years) were compared. The effects of modified constraint-induced-movement-therapy with bimanual training (54 h modified constraint-induced-movement-therapy, 18 h bimanual training, 8-10 weeks) was investigated by assessing spontaneous affected-upper-limb-use ("Assisting Hand Assessment"), manual abilities ("ABILHAND-kids") and subjective performance and satisfaction of problematic bimanual activities ("Canadian Occupational Performance Measure") at three time points (pre-treatment, post-treatment, follow-up). This data was analyzed using repeated-measures analysis. RESULTS Children with Brachial Plexus Birth Injury showed significant improvements on all outcome measures following modified constraint-induced-movement-therapy with bimanual training. These results were comparable to those observed in the group of children with unilateral Cerebral Palsy. DISCUSSION These results suggest that modified constraint-induced-movement-therapy with bimanual training is effective in Brachial Plexus Birth Injury. They indicate a comparable improved bimanual performance in children with Brachial Plexus Birth Injury than in unilateral Cerebral Palsy and suggests that both groups of children have affectively overcome their developmental disregard.IMPLICATIONS FOR REHABILITATIONChildren with Brachial Plexus Birth Injury frequently experience difficulties in activities of daily living.It has recently been suggested that children with Brachial Plexus Birth Injury may also show a non-use of the affected upper limb despite sufficient capacity, called developmental disregard.Children with Brachial Plexus Birth Injury and developmental disregard might therefore benefit from intensive therapies aimed at overcoming developmental disregard, originally developed for children with unilateral Cerebral Palsy.A combination of modified Constrained-Induced Movement Therapy with intensive Bimanual Training has shown to be affective in children with unilateral Cerebral Palsy.In a small sample, this study shows that a combination of modified Constrained-Induced Movement Therapy with intensive bimanual training is effective in children with Brachial Plexus Birth Injury, comparable and even more than in unilateral Cerebral Palsy.
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Affiliation(s)
- Ingar M Zielinski
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands.,Department of Child and Adolescent Psychiatry and Psychotherapy, RWTH Aachen University, Aachen, Germany
| | - Renske van Delft
- Merem Rehabilitation Centre De Trappenberg, Huizen, The Netherlands
| | | | - Alexander C H Geurts
- Department of Rehabilitation, Radboud University Medical Centre, Nijmegen, The Netherlands.,Donders Centre for Neuroscience, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Bert Steenbergen
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands.,School of Psychology, Australian Catholic University, Melbourne, Australia
| | - Pauline B M Aarts
- Department of Pediatric Rehabilitation, Sint Maartenskliniek, Nijmegen, The Netherlands
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Simon NG, Franz CK, Gupta N, Alden T, Kliot M. Central Adaptation following Brachial Plexus Injury. World Neurosurg 2016; 85:325-32. [DOI: 10.1016/j.wneu.2015.09.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 09/14/2015] [Accepted: 09/15/2015] [Indexed: 12/11/2022]
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