Reliability and validity of the Brachial Plexus Outcome Measure in children with obstetric brachial plexus palsy

Effect of Muscle Strength on Functionality after Shoulder Tendon Transfer in Brachial Plexus Birth Injury: Is There a Relationship between Them?

BACKGROUND/OBJECTIVES

Secondary problems in BPBI occur due to decreased muscle strength in the upper extremities. Comprehensive assessment methods are necessary to understand structural problems and to plan appropriate interventions in children with BPBI. We investigated the relationship between distal muscle strength, range of motion (ROM), and functionality by comparing distal muscle strength on the affected and unaffected sides in patients with BPBI who underwent shoulder tendon transfer.

METHODS

A total of 25 children with BPBI, 13 (52%) girls and 12 (48%) boys, aged 4-7 years (mean age: 5.98 ± 1.27 years), who had undergone shoulder tendon transfer surgery at least one year prior to the study were included. The muscle strength of the elbow, forearm, and wrist were assessed using the MicroFET®2 Digital Hand Dynamometer. The ROM of the elbow, forearm, and wrist were measured using the universal goniometer. The Pediatric Evaluation of Disability Inventory (PEDI) was used for functionality assessment.

RESULTS

The strength of the elbow flexor-extensor, forearm pronator-supinator, and wrist extensor muscles on the affected side was greater than on the unaffected side in all children (p < 0.001). No correlation was found between muscle strength, ROM, and functionality in the affected extremity (p > 0.005).

CONCLUSIONS

Although children with BPBI have good shoulder function after shoulder tendon transfer, structural problems in the distal joints may affect their functionality during daily life. Distal joint strengthening and ROM exercises, as well as bimanual functional activities, should be included in the rehabilitation programs of children with BPBI after shoulder tendon transfer.

The Role of Virtual Reality and Functional Electrical Stimulation on a Seven-Year-Old Child With Erb's Palsy: A Case Report

Erb's palsy usually commonly arises from incidents such as falls, collisions, birth trauma, and shoulder injuries in children. It impairs upper extremity muscle function, which has an impact on the quality of life and social interaction. Physical therapy is beneficial in preserving and enhancing upper extremity function, improving the quality of life. In this case report, a seven-year-old female child with complaints of weakness in the right upper limb demonstrated a notable increase in the strength and function of the upper extremities after four weeks of structured rehabilitation using virtual reality and functional electrical stimulation.

Prevalence and factors associated with musculoskeletal complaints and disability in individuals with brachial plexus injury: a cross-sectional study

PURPOSE

(1) To determine the prevalence of musculoskeletal complaints (MSCs) in the non-affected bodily structures in individuals with brachial plexus injury (BPI) and (2) to analyse factors associated with MSCs and disability.

METHODS

Survey among individuals with BPI and a control group. Multivariable logistic and linear regression analyses were used to identify factors associated with MSCs or disability.

RESULTS

Forty-nine percent of individuals (34/70) with BPI experienced MSC, which was not significantly different from controls (35%, n = 40/113). Complaints were most often located in high back (OR  =  3.6) or non-affected limb (OR  =  2.2) or neck (OR  =  2.1). Greater disability was associated with the presence of MSC in individuals with BPI (OR  =  1.1, 95% confidence interval (95% CI) = 1.0; 1.1). Those with no or a low level of education (B = -10.2, 95% CI = -19.6; -1.4), a history of nerve surgery (B = 11.1, 95% CI = -0.2; 20.9), and moderately affected active range of motion (AROM) of the affected limb (B = 20.7, 95% CI  =  8.8; 31.0) experienced most disability. Individuals with severely affected AROM showed a wide range of experienced disability.

CONCLUSIONS

Clinicians should be aware that almost half of individuals with BPI have MSCs in the non-affected bodily structures, which was associated with increased disability.Implications for rehabilitationMusculoskeletal complaints of the non-affected limb, back and neck are common among individuals with brachial plexus injury, and are associated with more disability.Disability was associated with loss of active range of motion (AROM) in the affected limb, although there was a wide variation in experienced disability among individuals with no or a very limited AROM.

Recent Advances in the Treatment of Brachial Plexus Birth Injury

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation.

SUMMARY

Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade that include improved understanding of shoulder pathology and its impact on observed motor recovery, novel surgical techniques, new insights in sensory function and pain, and global efforts to develop standardized outcomes assessment scales.

"How Well" and "How Often" questions for birth brachial plexus injury: a validity and reliability of the pediatric upper extremity motor activity log-revised

PURPOSE

The pediatric upper extremity motor activity log-revised (PMAL-R) is a structured interview that measures use of the affected arm in daily life in children with unilateral pathologies like hemiparetic cerebral palsy (CP) or birth brachial plexus injury (BBPI). This study investigated validity and test-retest reliability of the PMAL-R in children with BBPI.

MATERIALS AND METHODS

The PMAL-R was administered to parents of 132 children with BBPI between 5 and 9 years for validity, also 98 parents were re-interviewed after 3 weeks to establish test-retest reliability. Its concurrent validity was examined by correlating scores on the PMAL-R How Well (HW) and How Often (HO) scales with Brachial Plexus Outcome Measure (BPOM) and Pediatric Outcomes Data Collection Instrument (PODCI) scores.

RESULTS

PMAL-R scores were strongly correlated with BPOM scores (HW, r = 0.943, p < 0.001; HO, r = 0.897, p < 0.001), also strongly correlated with PODCI (HW, r = 0.799, p < 0.001; HO, r = 0.797, p < 0.001). PMAL-R test-retest reliability (intraclass correlation; HO = 0.997, HW = 0.998) and internal consistency (Cronbach's a; HO = 0.99, HW = 0.99) were high.

CONCLUSIONS

The PMAL-R has good reliability and validity for measuring everyday use of the affected arm with "how often" and "how well" questions in children with BBPI. Implications for rehabilitationThe pediatric upper extremity motor activity log-revised (PMAL-R) is the first tool to assess both "how often" and "how well" the affected arm is used in unimanual activities in children with BBPI.PMAL-R is a real-world measure providing valuable information about "how often" and "how well" the affected arm is used to guide treatment.PMAL-R is valid in both concurrent and discriminative validity in children with BBPI.PMAL-R is reliable in children with BBPI.

Assessment of the relationship between Brachial Plexus Profile activity short form scores and modified Mallet scores

INTRODUCTION

This study aims to assess the relationship between the modified Mallet classification and the Brachial Plexus Profile activity short form (BP-PRO activity SF). The therapist or surgeon classifies upper extremity movement for the modified Mallet classification, while the BP-PRO assesses parents' perceptions of difficulty performing activities.

PURPOSE

To provide a deeper understanding of the relationship of functional and perceived outcome measurements.

STUDY DESIGN

Prospective, correlational design.

METHODS

Eighty children with brachial plexus birth injuries were evaluated using the modified Mallet classification, while parents simultaneously answered the BP-PRO activity SF questions. All patients had undergone one of three surgical interventions to improve shoulder function. The relationship between the two measures, patient injury levels, and surgical histories were assessed.

RESULTS

The average modified Mallet scores and BP-PRO activity SF scores weakly correlated (r = 0.312, P = .005) and both measures differentiated between C5-6 and C5-7 injury levels (P = .03 and P = .02, respectively). Conversely, the modified Mallet scores could differentiate between the three surgical groups (F = 8.2, P < .001), while the BP-PRO activity SF could not (P = .54).

CONCLUSION

The results suggest that these tools measure different aspects of patient outcomes. The Mallet classification may be more focused on shoulder motion than the BP-PRO activity SF. Additional questions that specifically require shoulder function could be incorporated into the BP-PRO activity SF to improve understanding of patient/parent perceptions of shoulder function for children with brachial plexus injuries. Clinicians should be aware of the strengths, weaknesses, and limitations of each outcome assessment tool for appropriate use and interpretation of results.

Upper-limb function in Brachial Plexus birth palsy: Does the Pediatric Outcomes Data Collection Instrument correlate with the Brachial Plexus Outcome Measure?

Functional outcome assessment for children with brachial plexus birth palsy (BPBP) is essential. We aimed to investigate the association between the Brachial Plexus Outcome Measure (BPOM) and the Pediatric Outcomes Data Collection Instrument (PODCI) in children with BPBP and healthy matched controls, and to explore upper-limb function and the discriminative properties of the two tests. Thirty children, aged 6-14 years, diagnosed with BPBP and undergoing shoulder tendon transfer and 20 age-matched healthy controls were included. In both groups, the Turkish version of the PODCI, used to evaluate daily living activities, was implemented. The Turkish version of the BPOM, specifically developed for BPBP, was applied in children with BPBP. Test results, demographic and clinical characteristics were recorded. The mean age of children with BPBP was 8.53 ± 2.53 years and their BPOM Activity scale score was 42.93 ± 8.28. The PODCI Upper Extremity Function score (74.97 ± 23.49 vs. 100) and the PODCI Global Functioning score (89.20 ± 7.73 vs. 99.36 ± 7.73) were significantly lower in the BPBP group (p < 0.01). While there was a significant and very strong relationship between the BPOM Activity and PODCI Global Functioning scores (r = 0.845; p = 0.037), no correlation was found between the BPOM Self-Evaluation scale and PODCI Global Functioning score (r = 0.456; p = -0.141). The PODCI correlated with the BPOM Activity scale, providing an appropriate alternative measurement for upper-limb function in children with BPBP after shoulder tendon transfer.

Long-Term Hand Function Outcomes of the Surgical Management of Complete Brachial Plexus Birth Injury

PURPOSE

Hand function outcomes of primary nerve reconstruction for total brachial plexus birth injury (BPBI) are confounded by nerve roots left in continuity, inclusion of secondary procedures, and no assessment of the ability to perform activities of daily living. The purpose of this study was to evaluate the long-term hand function outcomes in a cohort of patients with a complete BPBI who had no nerve root in continuity prior to primary nerve reconstruction targeting the lower trunk.

METHODS

This single-center retrospective case series of complete BPBI included patients who underwent primary nerve reconstruction. The outcomes were assessed using the active movement scale (AMS) and brachial plexus outcome measure preoperatively and at the age of 4 and 8 years.

RESULTS

Fifty patients with a complete BPBI, of whom 82% (41/50) had an avulsion of C8-T1, underwent primary nerve reconstruction at a mean age of 4.1 months. Compared with the preoperative AMS scores, a statistically significant increase of AMS scores was observed at 4 and 8 years of age for all movements except forearm pronation. Between 4 and 8 years of age, there was a statistically significant improvement of external rotation of the shoulder and elbow flexion as well as diminution of thumb flexion. In the brachial plexus outcome measure assessment, there were 83% (24/29) at 4 years and 81% (21/26) at 8 years who had sufficient functional movement to perform wrist, finger, and thumb activities.

CONCLUSIONS

Functional hand outcome was restored to sufficiently perform bimanual activity tasks in 81% (21/26) of patients with a complete BPBI at 8 years of age. This affirmed that primary nerve reconstruction reinnervating the lower trunk can result in a functional extremity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Morbidity of Nerve Transfers for Brachial Plexus Birth Injury: A Systematic Review

BACKGROUND

The purpose of this article is to systematically review the peer-reviewed literature on the morbidity of nerve transfers performed in patients with brachial plexus birth injury (BPBI). Nerve transfers for restoration of function in patients with BPBI that fail nonoperative management are increasing in popularity. However, relatively little attention has been paid to the morbidity of these transfers in the growing patient. The authors systematically review the current literature regarding donor site morbidity following nerve transfer for BPBI.

METHODS

A systematic review of the Medline and EMBASE databases was conducted through February 2020. Primary research articles written in English and reporting donor site morbidity after nerve transfer for BPBI were included for review.

RESULTS

Thirty-six articles met inclusion criteria, all of which were retrospective reviews or case reports. There was great heterogeneity in outcomes assessed. With 5 year or less follow-up, all transfers were relatively well tolerated with the exception of the hypoglossal nerve transfer.

CONCLUSION

Nerve transfers are a well-recognized treatment strategy for patients with BPBI and have an acceptable risk profile in the short term. Full hypoglossal nerve transfers for BPBI are of historical interest. Donor site morbidity is grossly underreported. This review highlights the need for more objective and systematic reporting of donor site outcomes, and the need for longer term follow-up in these patients.

LEVEL OF EVIDENCE

Systematic review. Level III-therapeutic.

Effect of augmented biofeedback for improvement of range of motion and upper extremity functionality in obstetric brachial plexus injury: a randomised control trial

Background/Aims

The loss of mobility and functional activities of the upper limb are the main longstanding complications of obstetric brachial plexus injury. The aim of this study was to investigate the effect of the augmented biofeedback system in conjunction with traditional physical therapy on the range of motion and functional activities in children with obstetric brachial plexus injury.

Methods

A total of 45 children aged from 6 to 10 years with obstetric brachial plexus injury were assigned into two groups. The control group received a traditional physical therapy programme, and the study group received the same programme with augmented biofeedback for 6 weeks. The main outcome parameters were the upper limb active range of motion, Mallet scale and Active Movement scale.

Results

The children in the study group showed greater significant improvement in all measured parameters compared with those in the control group.

Conclusions

Adding augmented biofeedback to the physical therapy programme provided greater improvement in upper limb mobility and functional activities for children with obstetric brachial plexus injury children.

Brachial plexus birth injuries and the association between pre-procedure and post-procedure pediatric outcomes data collection instrument scores and narakas classification

BACKGROUND

The brachial plexus is a network of nerves exiting the spinal cord through the fifth, sixth, seventh, and eighth cervical nerves (C5-C8) as well as the first thoracic nerve (T1) to conduct signals for motion and sensation throughout the arm. Brachial plexus birth injuries (BPBI) occur in 1.5 per 1,000 live births. The purpose of this study was to determine the perceived change in musculoskeletal health-related quality of life of brachial plexus patients utilizing the Pediatric Outcomes Data Collection Instrument (PODCI). PODCI scores were examined along with the patient's procedure history (surgical or Botulinum Toxin), extent of involvement and demographics.

PATIENTS

A total of 81 patients from two to eighteen years of age from nine different states met the inclusion criteria of having a pre-procedure and post-procedure PODCI score along with a Narakas score from 2002-2017. These patients were seen at the Brachial Plexus Center, which is an interdisciplinary clinic at a large academic medical centerMETHODS: This retrospective study utilized PODCI data collected annually during their regular brachial plexus clinic visits. Upper extremity (UE) and global functioning (GFx) scores pre- and post-procedure were stratified by Narakas Classification. Data were analyzed using paired t-test and ANOVA testing.

RESULTS

Patients with a Brachial Plexus Birth Injury (BPBI) had lower PODCI scores for UE and GFx when compared with the pediatric normative scores for age-matched healthy children. Scores in both UE and GFx domains were higher after procedure in the groups of Narakas I and IV. There was significant correlation between UE and GFx scores and documented first PODCI score (2 years of age) and age at intervention (5 years of age).

CONCLUSION

Procedures increased the perceived quality of life for children with a BPBI and increased their overall PODCI scores for both UE and GFx.