Active Movement Scale Research Articles

Results of nerve reconstructions in treatment of obstetrical brachial plexus injuries.

The aim of this study was to evaluate the results achieved using various surgical techniques in patients with partial and total obstetrical brachial plexus palsy. From 2000 to 2013, 33 patients with obstetrical brachial plexus injury underwent surgery. Twenty had follow-up periods greater than 24 months and met the criteria for inclusion in the study. All patients were evaluated using the Active Movement Scale. The outcomes of different nerve reconstructive procedures including nerve transfers, nerve grafting after neuroma resection and end-to-side neurorrhaphy are presented. The overall success rate in upper plexus birth injury was 80 % in shoulder abduction, 50 % in external rotation and 81.8 % in elbow flexion with median follow-ups of 36 months. Success rate in complete paralysis was 87 % in finger and thumb flexion, 87 % in shoulder abduction and 75 % in elbow flexion; the median follow-up was 46 months. Useful reanimation of the hand was obtained in both patients who underwent end-to-side neurotization. Improved function can be obtained in infants with obstetrical brachial plexus injury with early surgical reconstruction.

Comparison of visual and objective quantification of elbow and shoulder movement in children with obstetric brachial plexus palsy.

BackgroundThe Active Movement Scale is a frequently used outcome measure for children with obstetric brachial plexus palsy (OBPP). Clinicians observe upper limb movements while the child is playing and quantify them on an 8 point scale. This scale has acceptable reliability however it is not known whether it accurately depicts the movements observed. In this study, therapist-rated Active Movement Scale grades were compared with objectively-quantified range of elbow flexion and extension and shoulder abduction and flexion in children with OBPP. These movements were chosen as they primarily assess the C5, C6 and C7 nerve roots, the most frequently involved in OBPP. Objective quantification of elbow and shoulder movements was undertaken by two-dimensional motion analysis, using the v-scope.MethodsYoung children diagnosed with OBPP were recruited from the Royal Children's Hospital (Melbourne, Australia) Brachial Plexus registry. They participated in one measurement session where an experienced paediatric physiotherapist facilitated maximal elbow flexion and extension, shoulder abduction and extension through play, and quantified them on the Active Movement Scale. Two-dimensional motion analysis captured the same movements in degrees, which were then converted into Active Movement Score grades using normative reference data. The agreement between the objectively-quantified and therapist-rated grades was determined using percentage agreement and Kappa statistics.ResultsThirty children with OBPP participated in the study. All were able to perform elbow and shoulder movements against gravity. Active Movement Score grades ranged from 5 to 7. Two-dimensional motion analysis revealed that full range of movement at the elbow and shoulder was rarely achieved. There was moderate percentage agreement between the objectively-quantified and therapist-rated methods of movement assessment however the therapist frequently over-estimated the range of movement, particularly at the elbow. When adjusted for chance, agreement was equal to chance.ConclusionVisual estimates of elbow and shoulder movement in children with OBPP may not provide true estimates of motion. Future work is required to develop accurate, clinically-acceptable methods of quantifying upper limb active movements. Since few children attained full range of motion, elbow and shoulder movement should be monitored and maintained over time to reduce disability later in life.

An Early Shoulder Repositioning Program in Birth-Related Brachial Plexus Injury: A Pilot Study of the Sup-ER Protocol

Birth-related brachial plexus injury (BRBPI) occurs in 1.2/1,000 births in British Columbia. Even in children with "good" recovery, external rotation (ER) and supination (Sup) are often weaker, and permanent skeletal imbalance ensues. A preventive early infant shoulder passive repositioning program was created using primarily a novel custom splint holding the affected arm in full ER and Sup: the Sup-ER splint. The details of the splint and the shoulder repositioning program evolved with experience over several years. This study reviews the first 4years. A retrospective review of BCCH patients managed with the Sup-ER protocol from 2008 to 2011 compared their recovery scores to matched historical controls selected from our database by two independent reviewers. The protocol was initiated in 18 children during the study period. Six were excluded due to the following: insufficient data points, non-compliance, late splint initiation, and loss to follow-up. Of the 12 matches, the Sup-ER group final score at 2years was better than controls by 1.18 active movement scale (AMS) points (p = 0.036) in Sup and 0.96 AMS points in ER (but not statistically significant (p = 0.13)). Unexpectedly, but importantly, during the study period, zero subjects were assessed to have the active functional criteria to indicate brachial plexus reconstruction, where previously we operated on 13%. Early application of passive shoulder repositioning into Sup and ER may improve outcomes in function of the arm in infants with BRBPI. A North American multi-site randomized control trial has been approved and has started recruitment.

영아 상완신경총 손상 치험 1례

Abstract A Case Report of Neonatal Brachial Plexus Palsy Jeong A Ram ․ Kim Ki-bong ․ Cheon Jin-Hong Department of Pediatrics, College of Oriental Medicine, Pusan National University Objectives The objective of this study is to report the effects of acupuncture on neonatal brachial plexus palsy (neonatal brachial plexopathy). Methods We treated the patient with acupuncture for 4 months. Acupuncture was performed on the infant with flaccid paresis of a lower extremity. The effects of neonatal brachial plexus injury were measured by the active movement scale and the electromyographic test. Results 1. In electromyographic test, conduction velocity in left median nerve was elevated.2. Active movement scale score was increased from 6 to 27 during the 4 months of treatment. 3. Grasping power of the patient‘s left hand was 60% stronger than the first medical examination. Conclusions This study showed that acupuncture was effective in treating the symptoms of brachial plexopathy. The further studies might be also needed.

Early Functional Recovery of Elbow Flexion and Supination Following Median and/or Ulnar Nerve Fascicle Transfer in Upper Neonatal Brachial Plexus Palsy

Nerve transfers using ulnar and/or median nerve fascicles to restore elbow flexion have been widely used following traumatic brachial plexus injury, but their utility following neonatal brachial plexus palsy remains unclear. The present multicenter study tested the hypothesis that these transfers can restore elbow flexion and supination in infants with neonatal brachial plexus palsy. We retrospectively reviewed the cases of thirty-one patients at three institutions who had undergone ulnar and/or median nerve fascicle transfer to the biceps and/or brachialis branches of the musculocutaneous nerve after neonatal brachial plexus palsy. The primary outcome measures were postoperative elbow flexion and supination as measured with the Active Movement Scale (AMS). Patients were followed for at least eighteen months postoperatively unless they obtained full elbow flexion or supination (AMS = 7) prior to eighteen months of follow-up. Twenty-seven (87%) of the thirty-one patients obtained functional elbow flexion (AMS ≥ 6), and twenty-four (77%) obtained full recovery of elbow flexion against gravity (AMS = 7). Of the twenty-four patients for whom recovery of supination was recorded, five (21%) obtained functional recovery. Combined ulnar and median nerve fascicle transfers were performed in five patients and resulted in full recovery of elbow flexion against gravity and supination of AMS ≥ 5 for all five. Single-fascicle transfer was performed in twenty-six patients and resulted in functional flexion in 85% (twenty-two of twenty-six) and functional supination in 15% (three of twenty). Patients with nerve root avulsion were treated at a younger age (p < 0.01), had poorer preoperative elbow flexion (p < 0.01), and recovered greater supination (p < 0.01) compared with patients with dissociative recovery. Younger patients (p < 0.01) and patients with C5-C6 avulsion (p < 0.02) recovered the greatest supination. One patient sustained a transient anterior interosseous nerve palsy after median nerve fascicle transfer. Ulnar and/or median nerve fascicle transfers were able to effectively restore functional elbow flexion in patients with nerve root avulsion, dissociative recovery, or late presentation following neonatal brachial plexus palsy. Recovery of supination was less, with greater success noted in younger patients with nerve root avulsion.

Neurolysis alone as the treatment for neuroma-in-continuity with more than 50% conduction in infants with upper trunk brachial plexus birth palsy

The debate addressed in this article is that of surgical treatment methods for a neuroma-in-continuity. The authors of this study chose to test the hypothesis that more severe nerve injuries, as distinguished by < 50% conduction across a neuroma-in-continuity, could be treated with neuroma resection and grafting, whereas less severe nerve injuries, with > 50% conduction across the neuroma, could be treated with neurolysis alone. The goal of this study was to compare preoperative and postoperative Active Movement Scale (AMS) scores in children with upper trunk brachial plexus birth injuries treated with neurolysis alone if the neuroma's conductivity was > 50% on intraoperative nerve testing. Seventeen patients (7 male, 10 female) met the criteria for inclusion in this study. Surgery was done when the patients were an average of 10 months old (range 6-19 months). The authors analyzed AMS scores from the preoperative assessment, 1-year postoperative follow-up visit, and subsequent follow-up assessment as close to 3 years after surgery as possible (referred to in this paper as > 2-year postoperative scores). Comparison of preoperative and 1-year follow-up data showed significant improvement in shoulder abduction, flexion, external rotation, and internal rotation; elbow flexion and supination; and wrist extension. Comparison of preoperative findings and results of assessment at > 2-year follow-up showed significant improvement in shoulder abduction, flexion, external rotation; and elbow flexion and supination. At final follow-up, useful function (AMS score of 6 or 7) was achieved for elbow flexion in 14 of 16 patients, shoulder flexion in 11 of 15 patients, shoulder abduction in 11 of 16 patients, and shoulder external rotation in 5 of 15 patients. This report indicates that there is a subgroup of patients who can benefit clinically, with functional improvement of shoulder and elbow function, from treatment with neurolysis alone for upper trunk lesions demonstrating more than 50% conduction across the neuroma on intraoperative nerve testing. Patients with less than 50% conduction, indicating more severe disease, are treated with nerve resection and grafting in the authors' treatment algorithm.

Distal Nerve Transfers Are Effective in Treating Patients with Upper Trunk Obstetrical Brachial Plexus Injuries

Current surgical management of obstetrical brachial plexus injury is primary reconstruction with sural nerve grafts. Recently, the nerve-to-nerve transfer technique has been used to treat brachial plexus injury in adults, affording the benefit of distal coaptations that minimize regenerative distance. The purpose of this study was to test the hypothesis that nerve transfers are effective in reconstructing isolated upper trunk obstetrical brachial plexus injuries. Ten patients aged 10 to 18 months were treated with three nerve transfers: spinal accessory nerve to the suprascapular nerve for shoulder abduction and external rotation; a radial to axillary nerve for shoulder abduction; and ulnar or median nerve transfer to the musculocutaneous nerve for elbow flexion. Patients were assessed preoperatively and postoperatively using the Active Movement Scale. All patients were followed regularly for up to 2 years. Improvement in elbow and shoulder function was observed between 6 and 24 months. By 6 months, all patients passed the cookie test. At 24 months, shoulder abduction improved from 3.7 ± 0.6 to 5.0 ± 0.5, shoulder external rotation from 1.8 ± 0.4 to 4.3 ± 0.6, shoulder flexion from 3.7 ± 0.5 to 5.4 ± 0.5, elbow flexion from 3.7 ± 0.6 to 6.3 ± 0.2, and forearm supination from 2.1 ± 0.4 to 5.9 ± 0.2. There was no clinically appreciable donor-site morbidity. Nerve transfers reduced operative times compared with traditional nerve grafting procedures. Those patients showed significant gains in Active Movement Scale score by 24 months postoperatively, comparable to results achieved by nerve grafting. These findings support nerve transfers as a potential alternative treatment option for upper trunk obstetrical brachial plexus injuries. Therapeutic, IV.

A systematic review of evaluation methods for neonatal brachial plexus palsy

Neonatal brachial plexus palsy (NBPP) affects 0.4-2.6 newborns per 1000 live births in the US. Many infants recover spontaneously, but for those without spontaneous recovery, nerve and/or secondary musculoskeletal reconstruction can restore function to the affected arm. This condition not only manifests in a paretic/paralyzed arm, but also affects the overall health and psychosocial condition of the children and their parents. Currently, measurement instruments for NBPP focus primarily on physical ability, with limited information regarding the effect of the disablement on activities of daily living and the child's psychosocial well-being. It is also difficult to assess and compare overall treatment efficacy among medical (conservative) or surgical management strategies without consistent use of evaluation instruments. The purpose of this study is to review the reported measurement evaluation methods for NBPP in an attempt to provide recommendations for future measurement usage and development. The authors systematically reviewed the literature published between January 1980 and February 2012 using multiple databases to search the keywords "brachial plexus" and "obstetric" or "pediatrics" or "neonatal" or "congenital." Original articles with primary patient outcomes were included in the data summary. Four types of evaluation methods (classification, diagnostics, physical assessment, and functional outcome) were distinguished among treatment management groups. Descriptive statistics and 1-way ANOVA were applied to compare the data summaries among specific groups. Of 2836 articles initially identified, 307 were included in the analysis, with 198 articles (9646 patients) reporting results after surgical treatment, 70 articles (4434 patients) reporting results after medical treatment, and 39 articles (4247 patients) reporting results after combined surgical and medical treatment. Among medical practitioners who treat NBPP, there was equivalence in usage of classification, diagnostic, and physical assessment tools (that focused on the Body Function and Structures measure of the International Classification of Functioning, Disability, and Health [ICF]). However, there was discordance in the functional outcome measures that focus on ICF levels of Activity and Participation. Of the 126 reported evaluation methods, only a few (the Active Movement Scale, Toronto Scale Score, Mallet Scale, Assisting Hand Assessment, and Pediatric Outcomes Data Collection Instrument) are specifically validated for evaluating the NBPP population. In this review, the authors demonstrate disparities in the use of NBPP evaluation instruments in the current literature. Additionally, valid and reliable evaluation instruments specifically for the NBPP population are significantly lacking, manifesting in difficulties with evaluating the overall impact and effectiveness of clinical treatments in a consistent and comparative manner, extending across the various subspecialties that are involved in the treatment of patients with NBPP. The authors suggest that all ICF domains should be considered, and future efforts should include consideration of spontaneous (not practitioner-elicited) use of the affected arm in activities of daily living with attention to the psychosocial impact of the disablement.

A systematic review of evaluation methods for neonatal brachial plexus palsy

Object Neonatal brachial plexus palsy (NBPP) affects 0.4-2.6 newborns per 1000 live births in the US. Many infants recover spontaneously, but for those without spontaneous recovery, nerve and/or secondary musculoskeletal reconstruction can restore function to the affected arm. This condition not only manifests in a paretic/paralyzed arm, but also affects the overall health and psychosocial condition of the children and their parents. Currently, measurement instruments for NBPP focus primarily on physical ability, with limited information regarding the effect of the disablement on activities of daily living and the child's psychosocial well-being. It is also difficult to assess and compare overall treatment efficacy among medical (conservative) or surgical management strategies without consistent use of evaluation instruments. The purpose of this study is to review the reported measurement evaluation methods for NBPP in an attempt to provide recommendations for future measurement usage and development. Methods The authors systematically reviewed the literature published between January 1980 and February 2012 using multiple databases to search the keywords "brachial plexus" and "obstetric" or "pediatrics" or "neonatal" or "congenital." Original articles with primary patient outcomes were included in the data summary. Four types of evaluation methods (classification, diagnostics, physical assessment, and functional outcome) were distinguished among treatment management groups. Descriptive statistics and 1-way ANOVA were applied to compare the data summaries among specific groups. Results Of 2836 articles initially identified, 307 were included in the analysis, with 198 articles (9646 patients) reporting results after surgical treatment, 70 articles (4434 patients) reporting results after medical treatment, and 39 articles (4247 patients) reporting results after combined surgical and medical treatment. Among medical practitioners who treat NBPP, there was equivalence in usage of classification, diagnostic, and physical assessment tools (that focused on the Body Function and Structures measure of the International Classification of Functioning, Disability, and Health [ICF]). However, there was discordance in the functional outcome measures that focus on ICF levels of Activity and Participation. Of the 126 reported evaluation methods, only a few (the Active Movement Scale, Toronto Scale Score, Mallet Scale, Assisting Hand Assessment, and Pediatric Outcomes Data Collection Instrument) are specifically validated for evaluating the NBPP population. Conclusions In this review, the authors demonstrate disparities in the use of NBPP evaluation instruments in the current literature. Additionally, valid and reliable evaluation instruments specifically for the NBPP population are significantly lacking, manifesting in difficulties with evaluating the overall impact and effectiveness of clinical treatments in a consistent and comparative manner, extending across the various subspecialties that are involved in the treatment of patients with NBPP. The authors suggest that all ICF domains should be considered, and future efforts should include consideration of spontaneous (not practitioner-elicited) use of the affected arm in activities of daily living with attention to the psychosocial impact of the disablement.

Psychometric properties of outcome measures for children and adolescents with brachial plexus birth palsy: a systematic review

The aim of this review was to evaluate the psychometric properties of outcome measures used to quantify upper limb function in children and adolescents with brachial plexus birth palsy (BPBP). Eleven electronic databases were searched to identify studies on the effects of conservative management to improve upper limb function in young people with BPBP. Outcome measures used in these studies were extracted and used in a subsequent search to identify studies that evaluated the psychometric properties of these measures. The methodological quality of these studies was rated using a standardized critical appraisal tool. Thirty-three outcome measures and 12 psychometric studies were identified. Nine outcome measures had some psychometric evidence, which was variable in quality. The outcome measures which seem to have the most robust psychometric properties include the Active Movement Scale, Assisting Hand Assessment, Pediatric Evaluation of Disability Index, and the Pediatric Outcomes Data Collection Instrument. Further research is required to determine the psychometric properties of outcome measures used for children and adolescents with BPBP. Caution is required when interpreting the results of commonly used outcome measures in this population owing to their relatively unknown psychometric properties.

Functional Outcome after the Hoffer Procedure

Children with obstetrical brachial plexus injury often develop an internal rotation and adduction contracture about the shoulder as a secondary deformity, resulting in an inability to externally rotate and abduct the shoulder. The Hoffer procedure is evaluated for its potential benefit in improving shoulder abduction and external rotation and its impact on activities of daily living. This is a retrospective review of patients treated in brachial plexus injury clinic who underwent tendon transfer procedures about the shoulder. Preoperative and postoperative active movement and active range of motion were measured and recorded using the Mallet scale and the Active Movement Scale. Twenty patients were included in the study. Average age at time of surgery was 6.35 years. Thirteen patients had primary brachial plexus reconstructive surgery and four patients had concomitant wrist extension tendon transfer procedures. All patients had full passive range of motion preoperatively. The average follow-up period was 25.45 months. Average differences in pre-Hoffer and post-Hoffer Mallet scale scores are as follows: active abduction, 1.20; external rotation, 1.35; hand-to-neck, 1.25; hand-to-back, 0.75; hand-to-mouth, 0.65; and aggregate score, 5.20 (p<0.001 for all). Average differences in relevant pre-Hoffer and post-Hoffer Active Movement Scale scores are as follows: shoulder abduction, 2.10; shoulder external rotation, 4.25; and shoulder internal rotation, -0.80. All patients maintained full range of motion passively; thus, no functional loss was experienced. These results showed very high statistical significance (p<0.001 for all) and clinical significance. Younger patients (≤6 years) and those with better preoperative shoulder flexion and shoulder internal rotation yielded better postoperative results. The Hoffer procedure provides clinically and statistically significant improvement in external rotation and abduction while preserving functional internal rotation range in the child with obstetrical brachial plexus palsy and secondary shoulder deformity. Therapeutic, IV.

Botulinum Toxin for the Treatment of Motor Imbalance in Obstetrical Brachial Plexus Palsy

Residual muscle imbalance is a common problem affecting obstetrical brachial plexus palsy patients. The goal of this study was to examine the efficacy of botulinum toxin type A (Botox) in improving this muscle imbalance. The authors retrospectively reviewed obstetrical brachial plexus palsy patients treated with Botox for muscle imbalance as an isolated procedure. Outcomes were the change in Active Movement Scale scores from pre-Botox scores to scores at 1 month after Botox and 1 year after Botox. Twenty-seven patients were included, 19 treated for shoulder imbalance and eight treated for elbow imbalance. Active Movement Scale scores (mean±SD) for shoulder external rotation improved from 0.6±1.0 before Botox to 2.6±2.14 (p<0.01) at 1 month after Botox, and declined to 1.3±1.2 (p<0.01) at 1 year after Botox. Scores for elbow flexion were 3.3±2.1 before Botox, unchanged at 4.4±1.8 (p=0.07) 1 month after Botox, and improved to 5.8±0.5 (p<0.01) at 1 year after Botox. Scores for elbow supination were 2.9±1.7 before Botox and 3.4±1.5 (p=0.2) at 1 month after Botox, and improved to 3.9±2.0 (p<0.01) at 1 year after Botox. Botox for shoulder movement imbalance produces improvement in external rotation that is not sufficiently sustained over time to be of clinical benefit. However, Botox for elbow movement imbalance produces a sustained and clinically useful improvement. Therapeutic, IV.

Health-related quality of life in children with obstetrical brachial plexus palsy

We aimed to determine the health-related quality of life (HRQL) of children with obstetrical brachial plexus palsy (OBPP) and examine its association with gender, age, injury level, injured side, and functional status. We conducted a controlled, cross-sectional study including 70 children with OBPP. Fifty-two age-matched children without any health problems were included as controls. HRQL was assessed with the short parent form of the Child Health Questionnaire (CHQ-PF28), and functional status was measured using the active movement scale (AMS). Children with OBPP scored significantly lower on most of the CHQ-PF28 subscales than the healthy controls (p<0.05). Gender or age did not significantly affect scores in any domain (p>0.05). CHQ-PF28 scores showed that there were significant differences according to the side of injury between groups, especially in the "parental impact-time" and "family activities" domains (p<0.05). There were no statistically significant differences in CHQ-PF28 scores between groups that had an upper trunk involvement and total injury groups (p>0.05), except in the "bodily pain/discomfort" domain (p<0.05). The AMS score was weakly to moderately correlated with the "mental health" and "parental impact-time" and "general health perceptions" domains. The study demonstrated that children with OBPP have a poorer HRQL than their healthy peers. Side of injury, limitations in shoulder flexion, shoulder internal rotation, elbow flexion, elbow extension, and forearm supination were important factors affecting the HRQL of the children. The health concepts and factors discussed in the study can guide clinicians aiming to improve QoL of children with OBPP.

Combined Glenoid Anteversion Osteotomy and Tendon Transfers for Brachial Plexus Birth Palsy

In the setting of severe glenohumeral dysplasia secondary to brachial plexus birth palsy, external rotation osteotomy of the humerus has traditionally been used to transpose the existing arc of shoulder motion to a more functional position. Here we introduce a surgical alternative, the aim of which is to gain stable reduction of the shoulder and restore active external rotation. All patients with brachial plexus birth palsy and Waters type-III, IV, or V glenohumeral dysplasia who underwent glenoid anteversion osteotomy combined with tendon transfers between 2006 and 2009 were identified. The Mallet score, Active Movement Scale, and active and passive ranges of motion were used to assess functional outcomes. Axial imaging was used to measure glenoid version, the degree of subluxation, and the Waters type. Thirty-two patients with a median age of 6.8 years (range, 2.1 to 16.2 years) were followed for a mean of twenty months (range, twelve to twenty-nine months). On average, passive external rotation with the shoulder in neutral increased by 43° (95% confidence interval [CI], 26° to 60°), passive internal rotation decreased by 22° (95% CI, 12° to 31°), active external rotation with the shoulder in neutral increased by 82° (95% CI, 66° to 98°), and active internal rotation decreased by 26° (95% CI, 14° to 38°). The aggregate Mallet score improved by a mean of 4.0 points (95% CI, 3.0 to 4.9). Glenoid retroversion improved by a mean of 26° (95% CI, 20° to 32°). The percentage of the humeral head anterior to the midscapular line improved by a mean of 35% (95% CI, 30% to 40%). In patients with severe glenohumeral dysplasia, glenoid realignment osteotomy in conjunction with soft-tissue rebalancing permits maintenance of joint reduction and functional improvement in the short term. In our view, external rotation osteotomy of the humerus is no longer the only surgical option for these cases.

Impact of obstetrical brachial plexus injury on parents

The aim of this study was to describe the impact of obstetrical brachial plexus palsy (OBPP) on parents and to investigate the effect of the severity of OBPP and the age of the children on parents. A total of 106 parents (with a mean age of 30.14 ± 5.01 years) of children with OBPP were included in the study. The functional level of the children was assessed by the Active Movement Scale, whereas the impact of OBPP on the parents was assessed by the Turkish version of the Impact on Family Scale. The parents appeared to be moderately affected by their child's disorder. Financial, social, personal, mastery parameters and total impact values were 52% (27-77%), 65% (46-114%), 49% (31-67%), 51% (28-74%) and 56% (40-72%), respectively. Root involvement and the age of the children did not make a statistically significant difference in the level of impact. Detailed knowledge of the impact of OBPP on families might provide a chance to support affected families in coping with the situation and decrease their burden in providing care for the children. It is crucial to evaluate and provide social support to parents of children with OBPP.

Newborn brachial plexus palsy: Evaluation of severity using quantitative ultrasound of muscle

We studied ultrasound features of muscle after nerve injury. We evaluated ultrasound measurements of muscle thickness and backscatter in injured and contralateral uninjured elbow flexors of 51 children with newborn brachial plexus palsy (NBPP) and compared the results to elbow flexor function (Active Movement Scale), defined as normal, moderate, or severe. Compared with uninjured limbs, muscle in injured arms was 15% thinner with severe impairment, 17% thicker with moderate impairment, and no different with normal function. Relative to uninjured limbs, moderately impaired muscle was thicker than both severely impaired and normal strength muscle. Backscatter was higher in injured than in uninjured limbs regardless of function. In 17 patients with sequential measures, muscle thickness, but not backscatter, increased with function over time. Muscle thickness differentiates moderate from severe impairment after NBPP and increases with recovery over time. Muscle backscatter identifies prior injury regardless of function.

The Brachial Plexus Outcome Measure: Development, Internal Consistency, and Construct Validity

PurposeThe purpose of this article was to report the development of a new assessment tool, the Brachial Plexus Outcome Measure (BPOM) and the evaluation of its internal consistency and construct validity. MethodsA retrospective case series of children aged 4–19 years with obstetrical brachial plexus palsy (OBPP) was conducted. Intraclass coefficients were calculated for the BPOM Activity Scale items. Correlation between the Active Movement Scale (AMS) and BPOM Activity Scale scores were conducted to determine the convergent validity. ResultsThe BPOM Activity Scale items (N=306) had good internal consistency (Cronbach's α=0.87). A strong correlation between the BPOM Activity Scale and AMS (n=284) was found (r=0.71, p=0.001, α=0.05). ConclusionsThe BPOM Activity Scale demonstrates good internal consistency and construct validity as a discriminative functional outcome measure in children with OBPP. Level of EvidenceIV

Quality of life in mothers of children with obstetrical brachial plexus palsy

The aim of this study was to explore impairment in quality of life (QOL) of the mothers who were primarily responsible for taking care of children with obstetrical brachial plexus palsy (OBPP) and to state its association with the age, sex and functional status of the child with OBPP. Ninety-three mothers of children with OBPP and 88 mothers of children without any health problems were included in the study. Children's demographic characteristics were recorded and the functional status of the upper extremity was determined with the active movement scale. The QOL of the mothers was assessed with the Turkish version of the Nottingham Health Profile (NHP). There were significant differences between mothers of children with OBPP and the control group in total, physical activity, energy expenditure, and pain score of the NHP. A decrease in energy expenditure and physical activity levels were found to be related to children's active movement scale results in elbow flexion and extension, and forearm supination. A statistically meaningful difference was found between mothers of children aged 0-2 and mothers of children aged 2-7 years in emotional reaction, social isolation and total score of NHP. The results of this study revealed that mothers of children with OBPP have poor QOL compared with mothers of healthy children. The limitation in elbow joint movements was found to be important for the mothers. The strongest impact of the illness is on the emotional reactions and social isolation of the mothers. Professionals involved in the care of children with OBPP should also help parents to cope with the burden of caregiving.

Functional contribution of T1 to the brachial plexus in infants

To determine the contribution of the T1 root to movements of the upper limb in infancy, 40 infants presenting with obstetrical brachial plexus palsy who underwent resection and reconstruction of all brachial plexus roots with the exception of the T1 root were assessed in the early postoperative period. The movements of the limb were recorded using the Hospital for Sick Children active movement scale and demonstrated considerable variability. All movements of the upper limb were observed in this group with the exception of external rotation of the shoulder and elbow flexion. Classical accounts of the function of T1 have limited its activity to the small muscles of the hand and were based on anatomical dissection, brachial plexus injuries and electrical stimulation. By contrast, this study isolated the physiological activity of T1 and analysed the functional contribution of this root to arm movement. We show a greater than generally recognized contribution of T1 to the function of the upper limb in infants.

Suprascapular Nerve Reconstruction in Obstetrical Brachial Plexus Palsy: Spinal Accessory Nerve Transfer versus C5 Root Grafting

The purpose of this study was to determine whether there is any difference in external rotation following reconstruction of the suprascapular nerve using nerve grafts from the proximal C5 root or nerve transfer using the spinal accessory nerve. External rotation was assessed using the Active Movement Scale immediately before surgery and 3 years postoperatively. Patients with less than 3 years of follow-up were excluded. For patients who underwent secondary shoulder surgery before the 3-year follow-up, the Active Movement Scale score before shoulder surgery was used as the outcome. One-hundred-six patients underwent nerve grafting, while 71 patients underwent spinal accessory nerve transfer. The spinal accessory nerve transfer group had a greater proportion of patients with total plexus palsies, more avulsions, and an earlier age at surgery (p < 0.001). In the C5 nerve graft group, the mean Active Movement Scale score increased from 0.4 to 2.2 (p < 0.001). In the nerve transfer group, the mean score increased from 0.2 to 3.0 (p < 0.001). Preoperatively, the C5 nerve graft group had significantly better scores than the nerve transfer group (p = 0.03). Postoperatively, there was no significant difference between treatments (p = 0.1). Further statistical analysis failed to demonstrate a significant advantage of one surgical treatment over the other. There was no difference in external rotation after suprascapular nerve reconstruction with either nerve grafting from the proximal C5 root or spinal accessory nerve transfer. The choice of suprascapular nerve reconstruction can be selected depending on specific requirements of the individual lesion.