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Journal of Hand Therapy 27 (2014) 335e340

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Journal of Hand Therapy

journal homepage: www.jhandtherapy.org

JHT READ FOR CREDIT ARTICLE #331.Practice Forum

Sup-ER orthosis: An innovative treatment for infants with birthrelated brachial plexus injury

Kim M. Durlacher MRSc, BScOT, CHTa,b,c,*, Doria Bellows BScPT d, Cynthia Verchere MD, FRCSC e,f,g

aDepartment of Occupational Therapy, British Columbia Children’s Hospital, Vancouver, CanadabDepartment of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, CanadacDepartment of Physical Therapy, University of British Columbia, Vancouver, CanadadDepartment of Physiotherapy, British Columbia Children’s Hospital, Vancouver, CanadaeDivision of Pediatric Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, CanadafDepartment of Surgery, University of British Columbia, Vancouver, CanadagChild & Family Research Institute, Vancouver, Canada

* Corresponding author. BC Children’s HospDepartment e Rm K1-200, 4480 Oak Street, Vancouv604 875 2123; fax: þ1 604 875 3220.

E-mail address: kdurlacher@cw.bc.ca (K.M. Durlac

0894-1130/$ e see front matter � 2014 Hanley & Belhttp://dx.doi.org/10.1016/j.jht.2014.06.001

Impairments in active and passive range of upper extremity supination and shoulder external rotation arecommon sequelae for children with delayed recovery from birth related brachial plexus injury. Orthoticintervention may complement traditional treatment strategies commonly employed in the newborn period.These authors describe their custom fabricated orthosis designed to balance shoulder growth and muscularfunction, and improve prognosis of long term functional outcomes for children with birth related brachialplexus injury. e VICTORIA PRIGANC, PhD, OTR, CHT, CLT, Practice Forum Editor

.

Birth related brachial plexus injury (BRBPI) occurs in 0.9e4.6/ use, and henceforth is seldom mentioned in modern literature.10

1000 births globally,1e6 with spontaneous recovery of functionallevels reported to occur in 50e92% of patients.1,2,6e9 Almost uni-versal outcomes of BRBPI, even for childrenwith otherwise “good”recovery, are impairments in both active and passive range ofupper extremity supination (Sup) and shoulder external rotation(ER).4,6,10 Poorly positioned (Fig. 1) and contracted shouldermusculature, and associated skeletal changes can secondarilyprevent full range of even otherwise recovered muscle action, andpotentially result in significant functional consequences.9 Whileawaiting maximal nerve recovery, traditional treatment goalshave included prevention of joint contractures, strengthening ofrecovering muscles, sensory stimulation, and encouraging devel-opmental milestones.9

Ter Steeg, Hoeksma, Dijkstra, Nelissen & De Jong (2003) re-ported that shoulder bracing for BRBPI was recommended in thefirst half of the twentieth century, but subsequently advised againstwith inference made to concerns related to the development ofshoulder ER and abduction contractures associated with orthotic

ital Occupational Therapyer, Canada V6H 3V4. Tel.: þ1

her).

fus, an imprint of Elsevier Inc. All

However, orthotic use is described by Chan (2002) as one of themost useful modalities to prevent joint contractures, minimizedeformities, and substitute loss of motor control following a pe-ripheral nerve injury.11 Ter Steeg et al (2003) concluded that the useof arm braces “during the period of flaccid palsy of the shouldermuscles be reconsidered, but could only be justified after a ran-domized clinical trial” (p. 7).10

Purpose of this orthosis

Our clinic team speculated that if the arm could be practically,safely, and comfortably supported for the majority of the day in aposition of the most glenohumeral congruity achievable and withthe tightest muscles held lengthened (i.e. into forearm supinationand shoulder external rotation) then the normal anatomic growthof the shoulder may be better maintained until nerve recoveryallowed for active movement to return.12 Indications for use of theSup-ER orthosis (Fig. 2) include infants presenting with majorweakness or tightness of shoulder ER, beyond the recovery periodanticipated for a neuropractic injury. At our center, based onclinical assessment of the child at about 4e8 weeks of age,defining criteria include tightness in passive range of motion ofshoulder external rotation (any angle of less than 180� from the

rights reserved.

Fig. 1. Typical arm resting posture in BRBPI.

Fig. 3. Waistband pattern.

K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340336

abdomen in ER), and/or, using the Toronto Active MovementScale,13 a score of ER � 2, and/or Sup � 2.12

Materials used

� 1.6 mm aquaplast (or preferred light weight thermoplastic),preferably not perforated

� Neoprene plush� Velcro

- Hook and loop- Adhesive and non-adhesive

Fig. 2. Right arm Sup-ER orthosis (With kind permission from Springer Science andBusiness Media).12

� 2 D-rings and rivets, or thermoplastic hooks� Hapla fleece� Super wrap by Fabrifoam

Fabrication

Waistband

� See Fig. 3 for pattern and required measurements.� Trace pattern and cut out neoplush.� Sew Velcro closures to waist band and nappy strap (Fig. 8).

Long arm orthosis

1. To create a pattern, measure the baby’s arm length from thedistal metacarpal phalanges to top of the humerus, and armcircumference at largest part. This will give you a rectangularpattern.� Cut out thermoplastic.

2. Punch a hole for the thumb, positioned about 1 inch from longedge and 3/4 inch from width edge of thermoplastic.

3. With the arm positioned in 15e20� wrist extension, andmaximum tolerated supination and elbow extension, slidethumb through the hole and mold the thermoplastic on theanterior surface of the arm/hand, wrapping circumferentially tosecure the thermoplastic in place while positioning. Stay as highup the arm as possible.

4. Once thermoplastic has cooled, remove from the infant’s armand trim edges as needed.� Do not trim the thumb hole too large as the orthosis mayrotate on the hand if the infant is resisting the supinatedposition.

� Clear the distal palmar crease.� Cut proximal end on an angle to optimize orthotic lengthlaterally without impinging on the axilla.

5. Line edges with hapla fleece (for comfort).6. Anchor Velcro strap across dorsal hand (Fig. 4), to assist care-

givers in securing the orthosis on the arm.7. Attach Velcro straps (using rivet and D-ring for added adjust-

ability, or thermoplastic hook) at (1) lateral elbow, and (2)proximal/anterior aspect (Fig. 6).� These straps should be long enough to extend from theorthosis to the posterior aspect of the trunk, to secure the armin SUP and shoulder ER when the baby is lying supine.

Fig. 4. Apply orthosis (With kind permission from Springer Science and BusinessMedia).12

K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340 337

Assembly

Part 1

1. With the palm facing up (supination), apply the orthosis to theanterior aspect of arm/hand (Fig. 4).

2. Secure soft Velcro strap over dorsum of hand.3. With the arm still in supination, apply the super wrap. Thread

thumb through the hole that you have cut approximately 1½inches from the end, with end of thewrap pointing into the palm(Fig. 5). Loop wrap around the hand, and through a secondthumbhole to secure. Apply gentle even tension, with pull in thedirection of supination. Overlap the wrap by approximately halfits width as you proceed up the arm, avoiding the hooks/D-rings

Fig. 5. Apply wrap.

(Figs. 6 and 7). Youmay also cut slits in the wrap to thread the D-ring through.

Note: The direction of pull of the wrap and maintaining armsupination while wrapping are key to maintaining the supinationposition of the arm.

Part 2

1. Apply the waistband, pulling the nappy strap up between thelegs, like a diaper (Figs. 8 and 9).

2. Gently move the shoulder into ER and secure the Velcro strapsfrom the top of the arm and elbow to the posterior aspect of thewaistband (Fig. 10).

Note: Always position the shoulder with your hands, usingstraps to secure. Do not use straps to pull the shoulder intoposition.

Wear schedule

The recommended wear schedule will depend on the infant’sage and clinical assessment. Ideally orthotic use is initiated by 3months of age, up to 6 months of age. While the orthosis may beintroduced to older babies, tolerance to use (and thus familyparticipation) may present a greater challenge with more estab-lished contractures and/or patterns of movement of the involvedlimb. An intensive period of full time orthotic use (i.e. 22 h perday) is typically recommended initially, to build acceptance towear, and optimize the orthotic benefits during the infant period.During this stage parents are instructed to remove the entireorthosis at least two times per day to perform range of motionexercises, encourage age appropriate developmental activities,and address skin care needs. Additionally, removal of the shoulderVelcro straps (Part 2) is recommended when the child is feeding ortraveling in a car seat. This schedule is gradually tapered to nightand nap times to promote increasing opportunities for ageappropriate developmental stimulation in the growing child.

Fig. 6. Strap placement.

Fig. 7. Wrap complete. Fig. 8. Waistband.

K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340338

Regular monitoring and assessment of the child’s condition andorthotic fit are important to maintain efficacy of orthotic posi-tioning and fit, and to support individual developmental progressand recovery from BRBPI.

Caregiver education and participation are keys to successfulimplementation of this orthotic program. The importance ofcontinued range of motion exercises, sensory stimulation, and ageappropriate developmental play, in addition to orthotic use, areemphasized.

Fig. 9. Waistband application complete.

Early findings

A recent pilot study of the Sup-ER orthosis protocol12 completedat our center demonstrated the Sup-ER group final score at twoyears of age was better than controls by 1.18 Toronto ActiveMovement Scale13 points in Sup and 0.96 Toronto ActiveMovementScale13 points in ER. In addition, an unexpected finding was that nosubjects during the study period were assessed to have the activefunctional criteria to indicate brachial plexus reconstruction, whenpreviously 13% were operated on at our center.

Summary

In combination with active physiotherapy, use of the Sup-ERorthosis to passively position the affected arm into external

Fig. 10. Rotation strap application (With kind permission from Springer Science andBusiness Media).12

K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340 339

rotation and supination for recommended periods of time duringinfancy, may have a positive effect on balanced shoulder growth,muscular function, and prognosis for long term outcomes in pa-tients presenting with BRBPI. Formalized outcome studies arecurrently in development.

References

1. Hardy AE. Birth injuries of the brachial plexus: incidence and prognosis. J BoneJoint Surg Br. Feb 1981;63-B(1):98e101.

2. Rubin A. Birth injuries: incidence, mechanisms, and end results. Obstet Gynecol.Feb 1964;23:218e221.

3. Levine MG, Holroyde J, Woods Jr JR, Siddiqi TA, Scott M, Miodovnik M. Birthtrauma: incidence and predisposing factors. Obstet Gynecol. Jun 1984;63(6):792e795.

4. Hoeksma AF, Wolf H, Oei SL. Obstetrical brachial plexus injuries: incidence,natural course and shoulder contracture. Clin Rehabil. Oct 2000;14(5):523e526.

5. Chauhan SP, Rose CH, Gherman RB, Magann EF, Holland MW, Morrison JC.Brachial plexus injury: a 23-year experience from a tertiary center. Am J ObstetGynecol. Jun 2005;192(6):1795e1800. discussion 1800e1792.

6. Lagerkvist AL, Johansson U, Johansson A, Bager B, Uvebrant P. Obstetric brachialplexus palsy: a prospective, population-based study of incidence, recovery, andresidual impairment at 18 months of age. Dev Med Child Neurol. Jun2010;52(6):529e534.

7. Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF. The naturalhistory of obstetrical brachial plexus palsy. Plast Reconstr Surg. Apr 1994;93(4):675e680. discussion 681.

8. Gilbert A. Repair of the brachial plexus in the obstetrical lesions of thenewborn. Arch Pediatr. Mar 2008;15(3):330e333.

9. Waters PM. Update on management of pediatric brachial plexus palsy. J PediatrOrthop B. Jul 2005;14(4):233e244.

10. ter Steeg AM, Hoeksma AF, Dijkstra PF, Nelissen RG, De Jong BA. Orthopaedicsequelae in neurologically recovered obstetrical brachial plexus injury. Casestudy and literature review. Disabil Rehabil. Jan 7 2003;25(1):1e8.

11. Chan RK. Splinting for peripheral nerve injury in upper limb. Hand Surg. Dec2002;7(2):251e259.

12. Verchere C, Durlacher K, Bellows D, Pike J, Bucevska M. An early shoulderrepositioning program in birth-related brachial plexus injury: a pilot study ofthe Sup-ER protocol. Hand. March 2014;9(2):187e195. http://dx.doi.org/10.1007/s11552-014-9625-y.

13. Curtis C, Stephens D, Clarke HM, Andrews D. The active movement scale: anevaluative tool for infants with obstetrical brachial plexus palsy. J Hand SurgAm. May 2002;27(3):470e478.

K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340340

JHT Read for CreditQuiz: #331

Record your answers on the Return Answer Form found on thetear-out coupon at the back of this issue or to complete onlineand use a credit card, go to JHTReadforCredit.com. There isonly one best answer for each question.

#1. The article identifies the following as commonly problematicmotions with birth related brachial plexus injuries

a. supination and internal rotationb. external rotation and supinationc. pronation and supinationd. internal and external rotation

#2. Spontaneous functional recovery is reported at approximately

a. 25e50%b. 95%c. 75%d. 50e90%

#3. One of the primary aims of the orthosis is to rest the upper ex-tremity in a position which facilitates

a. minimum brachioradialis activityb. minimum teres minor activity

c. maximum glenohumeral congruityd. maximum biceps relaxation

#4. The following may be accurately said of this work: it is a

a. completed study with solid findingsb. preliminary investigation with encouraging findingsc. case studyd. a clinical report with no intension being viewed through a

scientific lens

#5. The name Sup-ER is a clever play on the word super

a. trueb. false

When submitting to the HTCC for re-certification, please batch yourJHT RFC certificates in groups of 3 or more to get full credit.