neonatal brachial plexus palsy - nchn

14/07/2015

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Neonatal brachial plexus palsy

Neonatal brachial plexus palsy

Toddlers and Pre Schoolers Allied Health Telehealth Session

Presented by: Fiona Sampson OT & Alison Chivers PT

https://www.surveymonkey.com/r/brachialplexusmanagement

14/07/2015


Indicators of Brachial Plexus Palsy

• Birth history often involving trauma

• Lack of movement in affected upper limb

• Lack of response to stimulation of affected arm

• Atypical posturing- ie waiter’s tip posture (internal rotation, pronation and wrist flexion)

Waiters tip

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http://emedicine.medscape.com/article/317057-overview




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Neonatal Brachial Plexus Palsy Protocol of Surgical Intervention

• 4-5 months : Severe injuries require nerve graft surgery.

• 9 months : Botox and casting considered for tightness into shoulder external rotation.

• 12 months : If shoulder external rotation movement is absent consider further botox and/or transfer of 1 nerve for external rotation.

• 18-24 months consider shoulder rebalancing (tendon transfer) if external rotation still limited.

When to refer to a specialist centre?

• Mild lesion cannot be distinguished reliably from severe lesions in the perinatal period.

• Only time reveals whether or not spontaneous recovery will occur.

• Absence of active flexion at one month of age is a good indicator for referral to a specialist centre.

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TODDLERS

Toddlers • Frequency of intervention

• Management of body function and structure

• Management of activity

and participation

• Surgical considerations

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Body Function and Structure

Maintenance of passive ROM • External rotation: most important • Adequate external rotation required

for movement above 90o

• Elbow extension

• Pronation / supination

Why do specific ROM losses occur?

• Growth

• Issues with denervated muscle

• Muscle imbalance

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Passive ROM: External Rotation

Difference between shoulder abducted and adducted

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Shoulder External Rotation Stretch

Pect Major, Ant Deltoid, Subscapularis, Teres Major, Latissimus Dorsi

Facilitating active movements

• Shoulder external rotation

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Facilitating active movements • Reaching into:

• shoulder abduction

• shoulder flexion

• Elbow extension

Facilitating active movements

• Supination and Pronation

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Specific strengthening

• Limits if muscle not adequately innervated

• Limits of cognitive understanding and cooperation

• E.g. Scapula winging/control

Strengthening • Developmentally

appropriate

• Positioning to eliminate gravity initially

• Progression to against gravity

• Functional goals

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Focus on affected upper limb development and function

• Prehension with affected hand

• Bimanual play development

PREHENSION: affected hand

• Initiation of reach

• Grasp and release

• Hands to midline

• Hand to mouth

• Prehension

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Prehension with affected hand

Digital grasp Pincer grasp

Bimanual upper limb development Issues:

• Focus on awareness of affected arm • Static stabilisation against body

• Static holding in affected hand

• Use of affected hand as assist (helper hand)

• Motor planning

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Developmental disregard and learned non use

Affected non dominant hand vs affected dominant hand

Reduced awareness of affected upper limb

Interventions Modified Constraint Induced Movement Therapy (Mod CIMT)

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Bimanual Therapy

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DOMINANCE • Affected dominant hand

Underlying weakness but easier to

facilitate use

• Affected non dominant hand

? Changing dominance

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Activities and Participation

• Child care

• Dressing

• Eating

• Pre-writing

• Play

• Climbing

• Early Ball skills

Pre Schoolers

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Management of body function and structure

• Maintenance of Passive ROM Shoulder external rotation

Elbow extension

Pronation / supination

• Facilitating active movements

Maintaining Passive ROM • Maintaining and facilitating

Shoulder external rotation

Elbow extension

Forearm pronation

• Child actively involved

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• Shoulder movements

• Abduction/ flexion

• External

• and internal rotation

Active movements

• Supination and pronation:

Gravity eliminated

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Supination Against gravity

Pronation: active

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Pre-Schoolers Activity and participation

• Table top fine motor function

– Prewriting development

– Stabilising paper

– Pencil grip

– Cutting

• Issues with hand dominance

• Shoulder internally

rotated

• Forearm across body

• Elbow off the table

• Forearm in mid position

Typical posture

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Ideal posture • Shoulder in mid position

• Hand at side of paper

• Forearm using full active pronation

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Bimanual skills

• Bimanual skill development

• Motor planning for bimanual tasks

Affected hand: dominant vs non dominant

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Cutting skills

Typical issues:

Wrist posture

Pronation or mid position of affected hand

Motor planning

Pre-Schoolers Activity and participation

• ADL issues and self help skills

(Developing independence)

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• Getting ready for school

–Ball skills

–Playground issues

• Falls

• Climbing

• Protection of arm

Interventions: Modified Constraint Induced Movement Therapy

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neonatal brachial plexus palsy - nchn

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