1
|
Dorich JM, Whiting J, Plano Clark VL, Ittenbach RF, Cornwall R. Impact of brachial plexus birth injury on health-related quality of life in adulthood: a mixed methods survey study. Disabil Rehabil 2024; 46:2042-2055. [PMID: 37199089 DOI: 10.1080/09638288.2023.2212917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 05/07/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE To describe the scope and nature of health concerns, functional impairments, and quality of life issues among adults with brachial plexus birth injury (BPBI). METHODS A mixed methods study was conducted by surveying two social media networks of adults with BPBI using a combination of closed-ended and open-ended questions regarding the role of BPBI on ones' health, function, and quality of life. Closed-ended responses were compared across ages and genders. Open-ended responses were qualitatively analyzed to expand upon the close-ended responses. RESULTS Surveys were completed by 183 respondents (83% female, age range 20-87 years). BPBI was reported to impact hand and arm use in 80% of participants (including affected and unaffected limbs and bimanual tasks), overall health in 60% (predominantly pain), activity participation in 79% (predominantly activities of daily living and leisure), life roles in 76% (predominantly occupation and parenting), and overall quality of life in 73% (predominantly self-esteem, relationships, and appearance). Significantly more females than males reported other medical conditions and an impact on hand and arm use and life roles. No other responses varied by age or gender. CONCLUSIONS BPBI affects many facets of health related quality of life in adulthood with variability among affected individuals.
Collapse
Affiliation(s)
- Jenny M Dorich
- Cincinnati Children's Hospital Medical Center, Departments of Orthopaedic Surgery and Allied Health Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - Jordyn Whiting
- Vice-President/Board of Directors, United Brachial Plexus Network, Reading, MA, USA
| | - Vicki L Plano Clark
- School of Education - Research Methods, University of Cincinnati, Cincinnati, OH, USA
| | - Richard F Ittenbach
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Roger Cornwall
- Cincinnati Children's Hospital Medical Center, Departments of Orthopaedic Surgery and Developmental Biology, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
2
|
Ogilvie KM, Mah AML, Klar K, Anthony A, Davidge KM, Clarke HM, Ho ES. Prevalence and predictors of elbow flexion contractures during early childhood following brachial plexus birth injury. J Hand Ther 2024:S0894-1130(23)00130-8. [PMID: 38342639 DOI: 10.1016/j.jht.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 08/10/2023] [Accepted: 09/16/2023] [Indexed: 02/13/2024]
Abstract
BACKGROUND Elbow flexion contracture development in school-age children with a brachial plexus birth injury (BPBI) is common. Reports indicate onset between 2 and 4 years; however, little is known about early childhood prevalence, development, and trajectory of these contractures. PURPOSE To determine the prevalence and predictors of BPBI elbow flexion contractures during early childhood. STUDY DESIGN A retrospective cross-sectional study. METHODS Demographic, diagnostic, treatment, and elbow contracture data were collected for children with a BPBI <4 years between 2015 and 2019 from a prospectively collected database. Spinal root motor contributions and injury were determined using Active Movement Scale (AMS) scores at 6 weeks of age and used to predict contracture development. RESULTS Of the 171 children that met inclusion criteria, 87% (n = 149) had upper plexus injuries. The mean age at the time of evaluation for an elbow contracture was 21.4 ± 12.7 months. The prevalence of elbow flexion contractures was 22% (n = 38), with mean onset at 13.4 ± 11.0 months. Mean contracture degree was -10.8 ± -6.9 degrees with 76% (n = 29) <-10 degrees. AMS shoulder abduction, flexion, and external rotation; elbow flexion; forearm supination; and wrist extension scores at a mean 2.3 ± 1.4 months were significantly lower in children who developed elbow flexion contractures (p < 0.001). Logistic regression found that low AMS elbow flexion with high elbow extension scores were a significant (p < 0.003) predictor of elbow contracture development. CONCLUSIONS The prevalence of elbow flexion contractures in early childhood is greater than previously understood. These findings indicate that C5-C6 injury affecting elbow flexion with relative preservation of elbow extension is a predictor of contracture development. Further research is needed to investigate the nature and sequelae of C5-C6 injury and its effects on elbow flexion contracture development.
Collapse
Affiliation(s)
- Karen M Ogilvie
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada; Alberta Health Services, Calgary, Canada
| | - Allison M L Mah
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Karen Klar
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Alison Anthony
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Kristen M Davidge
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Howard M Clarke
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada
| | - Emily S Ho
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada; Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada.
| |
Collapse
|
3
|
Ho ES, Ferdosi DV, Pourtousi A, Davidge KM, Anthony SJ. Mental health risk and protective factors associated with brachial plexus birth injuries: a scoping review. Disabil Rehabil 2024; 46:21-30. [PMID: 36562352 DOI: 10.1080/09638288.2022.2156628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/03/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE The purpose of this scoping review is to synthesize the current evidence on the risk and protective factors associated with mental health in children with brachial plexus birth injury (BPBI) and associated interventions. MATERIALS AND METHODS MEDLINE, EMBASE, and Cochrane databases were searched for reports on mental health in children with BPBI between 10 and 18 years. Risk and protective factors were charted using the VicHealth review and the Person-Environment-Occupation model. RESULTS Of 732 records found, 133 full text reports were reviewed and 16 reports were included. Multiple mental health risks associated with BPBI were identified, while protective factors were largely unexplored. Person-related risks were most common including negative coping strategies (n = 8, 50%) and pain (n = 6, 38%). Most frequently reported environment and occupation risk factors were social difficulties (n = 9, 56%) and challenges with upper limb function and daily activities (n = 6, 38%). Good self-determination and/or self-concept (n = 5, 30%) was the most common protective factor. CONCLUSIONS Research using a strengths-based approach is needed to elucidate protective factors and further understanding of the intersection of person and socio-cultural risk factors of mental health in children with BPBI.
Collapse
Affiliation(s)
- Emily S Ho
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Diba Vahidi Ferdosi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Ava Pourtousi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Kristen M Davidge
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
| | - Samantha J Anthony
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| |
Collapse
|
4
|
Muhlestein WE, Smith BW, Chang KWC, Justice D, Nelson VS, Brown SH, Yang LJS. Early referral to multidisciplinary specialty centers to optimize outcomes in children with neonatal brachial plexus palsy. Dev Med Child Neurol 2024; 66:117-124. [PMID: 37246332 DOI: 10.1111/dmcn.15658] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/30/2023]
Abstract
AIM To demonstrate the trajectory of long-term recovery of upper-extremity movement and determine optimal timing of evaluation at multidisciplinary specialty centers in children with neonatal brachial plexus palsy (NBPP). METHOD All children with conservatively managed NBPP seen at one institution from 2005 to 2020 were considered for inclusion. The cohort was divided according to age at formal evaluation (≤30 or > 30 days). Active range of motion (AROM) for shoulder and elbow movements collected at each appointment were compared in local age windows between early and late cohorts. Locally estimated scatterplot smoothing was used to demonstrate the trajectory of recovery for the overall cohort. RESULTS More than 13 000 prospectively collected data points for 429 children (220 males, 209 females) were analysed. Elbow flexion improved to nearly full AROM for both groups over the course of the study. Shoulder abduction, forward flexion and external rotation, and forearm supination improved for the entire cohort, although greater absolute improvement, particularly at the shoulder, was seen in the early cohort (age at formal evaluation ≤30 days). AROM for elbow extension remained roughly stable for the early cohort but decreased for the late cohort (age at formal evaluation >30 days). AROM for forearm pronation decreased over time for both cohorts. INTERPRETATION Our data demonstrate good long-term functional recovery for children with conservatively managed NBPP. However, early referral to multispecialty brachial plexus centers may optimize outcomes. WHAT THIS PAPER ADDS Many children with conservatively managed neonatal brachial plexus palsy have good long-term shoulder and elbow outcomes. Early referral to multidisciplinary clinics may maximize long-term shoulder and elbow recovery and optimize outcomes.
Collapse
Affiliation(s)
| | - Brandon W Smith
- Department of Neurologic Surgery, Duke University, Raleigh, NC, USA
| | | | - Denise Justice
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Virginia S Nelson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Susan H Brown
- School of Kinesiology, University of Michigan, Ann Arbor, MI, USA
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
5
|
Duff SV, Schmieg SL. Commentary on "The Relationship Between Elbow Flexion Postures and Overhead Reaching in Birth Brachial Plexus Injuries". Pediatr Phys Ther 2024; 36:70. [PMID: 38227750 DOI: 10.1097/pep.0000000000001081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Susan V Duff
- Chapman University Irvine, California Cedar Sinai Medical Center Los Angeles, California
| | | |
Collapse
|
6
|
Muhlestein WE, Chang KWC, Justice D, Nelson VS, Saadeh YS, Smith BW. Impact of Timing of Primary Nerve Surgery on Shoulder, Forearm, and Elbow Recovery in Neonatal Brachial Plexus Palsy. Neurosurgery 2023:00006123-990000000-01003. [PMID: 38108400 DOI: 10.1227/neu.0000000000002803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/06/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal brachial plexus palsy (NBPP) almost universally affects movement at the shoulder, elbow, and forearm. Timing of nerve reconstruction surgery to optimize long-term outcomes remains unknown. This study aimed to determine if timing of nerve reconstruction affects long-term recovery of an active range of motion (AROM) at the shoulder, elbow, and forearm in NBPP. METHODS We interrogated a prospectively collected database of all patients with NBPP who underwent primary nerve surgery at a single tertiary referral center between 2005 and 2020. The cohort was divided into those who underwent surgery at ≤6 or >6 months old and ≤9 or >9 months old. AROM for shoulder abduction, forward flexion, and external rotation, elbow flexion and extension, and forearm supination were collected at each visit. RESULTS Ninety-nine children were included in the analysis; 28 underwent surgery at ≤6 months old, 71 at >6 months, 74 at ≤9 months, and 25 at >9 months. There was no difference in AROM at 5 years for any of the movements between the ≤6- and >6-month groups. The ≤9-month group had significantly better shoulder forward flexion and elbow extension AROM than the >9-month group at a 5-year follow-up and better forearm supination at up to a 15-year follow-up. Patients who presented earlier were more likely to have earlier operations. CONCLUSION Surgery before 9 months may improve long-term upper extremity recovery in NBPP. Early referral should be encouraged to optimize timing of operative intervention.
Collapse
Affiliation(s)
| | - Kate W-C Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Denise Justice
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Virginia S Nelson
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Yamaan S Saadeh
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Brandon W Smith
- Department of Neurologic Surgery, Duke University, Durham, North Carolina, USA
| |
Collapse
|
7
|
Verchere C, Durlacher K, Bellows D. Management of Brachial Plexus Birth Injuries at British Columbia Children's Hospital. Semin Plast Surg 2023; 37:102-107. [PMID: 37503528 PMCID: PMC10371405 DOI: 10.1055/s-0043-1767783] [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: 07/29/2023]
Abstract
A multidisciplinary team at BC Children's Hospital provides brachial plexus birth injury management for our provincial catchment area. Although compared with many centers we service a relatively small clinic population, we have the benefit of universal health care, province-wide reach, and accessible research infrastructure. In 2008, we created the Sup-ER protocol, which includes an orthosis that passively positions the neonatal shoulder into more idealized glenohumeral contact during early growth. We have since shown that our Sup-ER patients have better shoulder outcomes, require less brachial plexus surgery, and need fewer shoulder tendon transfers than those patients treated in our clinic prior to 2008. We have also found that the rate and degree of elbow flexion contractures are reduced compared with results reported in the literature.
Collapse
Affiliation(s)
- Cynthia Verchere
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Pediatric Plastic Surgery, Department of Surgery, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Kim Durlacher
- Occupational Therapy Department, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Doria Bellows
- Physiotherapy Department, British Columbia Children's Hospital, Vancouver, BC, Canada
| |
Collapse
|
8
|
Yefet L, Bellows D, Bucevska M, Courtemanche R, Durlacher K, Hynes S, Verchere C. Can the Sup-ER Protocol Decrease the Prevalence and Severity of Elbow Flexion Deformity in Brachial Plexus Birth Injuries? Hand (N Y) 2023; 18:28S-35S. [PMID: 35658557 PMCID: PMC9896287 DOI: 10.1177/15589447221093673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Brachial plexus birth injuries (BPBIs) can often result in functional and cosmetic deficits including, according to a recent scoping review, elbow flexion contractures in up to 48%. A treatment algorithm that includes a custom long-arm orthosis to optimize early glenohumeral joint positioning (Sup-ER protocol) has been shown to improve shoulder range of motion. Although the protocol was not intentionally designed to affect the elbow, this study investigates the prevalence and severity of elbow flexion contractures in children treated with that protocol. METHODS This prospective cross-sectional cohort study examined 16 children aged 4 and older with BPBI severe enough to be treated with the Sup-ER protocol. Passive and active elbow flexion and extension range of motion (ROM) were assessed in both arms. Elbow flexion contractures were defined as > 5o from neutral. RESULTS Within the cohort of 16 patients (mean age: 7.0 years, range: 4.5-11.6 years), the mean maximal passive elbow extension was -6.2° in the affected arm and + 5.1° (hyperextension) in the unaffected arm. Zero patients had a severe elbow flexion contracture (>30o) and only 6/16 met the lowest threshold definition of elbow flexion contracture (>5o), with a mean onset at 22 months of age. CONCLUSIONS This study suggests an unintended decreased prevalence and severity of elbow flexion contractures in children with more severe BPBI treated with the Sup-ER protocol, relative to published values.
Collapse
Affiliation(s)
- Leeor Yefet
- The University of British Columbia, Vancouver, Canada
| | - Doria Bellows
- British Columbia Children's Hospital, Vancouver, Canada
| | | | | | - Kim Durlacher
- British Columbia Children's Hospital, Vancouver, Canada
| | - Sally Hynes
- The University of British Columbia, Vancouver, Canada.,British Columbia Children's Hospital, Vancouver, Canada
| | - Cynthia Verchere
- The University of British Columbia, Vancouver, Canada.,British Columbia Children's Hospital, Vancouver, Canada
| |
Collapse
|
9
|
Ho ES, Parsons JA, Davidge KM, Clarke HM, Wright FV. Shared decision making in youth with brachial plexus birth injuries and their families: A qualitative study. PATIENT EDUCATION AND COUNSELING 2021; 104:2586-2591. [PMID: 33766450 DOI: 10.1016/j.pec.2021.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The objective of this study is to elucidate the decision-making experiences of youth with brachial plexus birth injuries who face preference-sensitive decisions regarding treatment options for a persistent elbow contracture. METHODS Transcripts, research-created drawings, and field notes from in-depth interviews with 5 young adults and 14 youth-parent dyads, and 15 participant observation sessions of families and clinicians in the clinic setting were deductively and inductively coded and thematically analyzed. RESULTS Youth's shared decision making was influenced by relational processes with their clinicians and parents. Youth's trust in their clinicians' recommendations for pursuing treatment and pressure from their parents to pursue or continue rehabilitation treatment affected how their voices were expressed and heard. Parental emotional adjustment to the birth injury played a role in parental perceptions of what was deemed their youth's best interest in the shared decision. CONCLUSIONS The decision-making experiences of youth with brachial plexus birth injury illustrate the complexity of paediatric preference-sensitive decisions and the significance of social and emotional factors on these shared decisions. PRACTICE IMPLICATIONS Opportunity for youth to express their voice without external pressure during shared decision making is needed to make well-informed decisions based on their own values. Interventions such as decision coaching and decision support tools may help youth and parents to formally identify and discuss these relational processes.
Collapse
Affiliation(s)
- Emily S Ho
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada; Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada.
| | - Janet A Parsons
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Kristen M Davidge
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada
| | - Howard M Clarke
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada
| | - F Virginia Wright
- Department of Physical Therapy, University of Toronto, Toronto, Canada; Bloorview Research Institute, Toronto, Canada
| |
Collapse
|
10
|
Ho ES, Parsons JA, Davidge K, Clarke HM, Lawson ML, Wright FV. Developing a decision aid for youth with brachial plexus birth injuries facing treatment decisions for an elbow flexion contracture. PM R 2021; 14:971-986. [PMID: 34259390 DOI: 10.1002/pmrj.12677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 05/27/2021] [Accepted: 07/02/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND A common sequela of brachial plexus birth injury (BPBI) is an elbow flexion contracture. Youth with BPBI and their families face rehabilitation or surgical decisions that ideally entail careful deliberation of the risks and benefits of treatment within the context of the child's and family's functional and appearance-related goals. OBJECTIVE To develop a patient decision aid (PtDA) following International Patient Decision Aid Standards to help these youth and their families make treatment decisions. DESIGN Mixed-methods study. SETTING Brachial plexus clinic in a pediatric tertiary care center. PARTICIPANTS Five young adults (21-24 years), 14 youth (8-19 years) and their parents, 15 families (children 2-16 years), and 19 clinicians from a brachial plexus clinic participated in the PtDA development. Seventeen other youth (8-18 years) facing treatment decisions regarding their elbow contracture field tested the PtDA prototype. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES In-depth interviews and participant observation to conduct a decisional needs assessment of young adults, youth, parents, and health care professionals involved in these shared decisions. Cognitive interviews to field test the PtDA prototype. RESULTS Evidence from previously conducted knowledge synthesis and the youth-focused decisional needs assessment qualitative data informed the development of new PtDA prototype, which included a questionnaire-based values clarification method for youth to rate what matters most to them regarding their elbow function, appearance, psychosocial impact, and treatment options. The majority (90%) of youth >11 years who field tested the PtDA prototype understood its content, whereas only 29% of those between 8 and 11 years demonstrated independent comprehension. The majority (69%) responded that they would prefer to use the PtDA on their own either at home or in the clinic waiting room. CONCLUSIONS This new PtDA can be used to help youth with BPBI and their families to make a personal value-based informed decision regarding treatment options for their elbow flexion contracture.
Collapse
Affiliation(s)
- Emily S Ho
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Janet A Parsons
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Kristen Davidge
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Howard M Clarke
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - F Virginia Wright
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.,Bloorview Research Institute, Toronto, Ontario, Canada
| |
Collapse
|