Brachial Plexus Outcome Measure Research Articles

Patient reported outcomes in brachial plexus birth injury: results from the iPLUTO world‐wide consensus survey

Purpose Brachial plexus birth injuries (BPBI) can have lifelong effects on the development and functional use of the upper extremity. Currently there is no agreement with regards to what patient-reported outcome (PRO) measures should be used. Therefore, the ability to compare the effects of treatment between individuals and institutions is challenging. This study aimed to achieve consensus among clinicians on the use of PRO measures within this patient group to allow for improved comparison of treatments and outcomes in the future. Materials and Methods Online, a 3 round Delphi survey was completed by 35 international multi-disciplinary specialist centers. Results All respondents (100%) agreed that PRO measures are useful for clinical evaluation and patient treatment. None of the outcome measures scored >75% agreement for ability to assess responsiveness and current state in children with BPBI as most outcome measures were judged as not specific for BPBI. Additionally, participant centers were asked their perspective on the best available PRO option for each of the 3 categories: functional use of the upper limb, quality of life and pain. This resulted in endorsement by the participant centers of the Brachial Plexus Outcome Measure – Self-Evaluation, the Pediatric Quality of Life Inventory, and Visual Analogue Scale/Brief Pain Inventory respectively. Conclusion International specialists in BPBI agree that PRO measures are important to use both clinically and in research in children aged 5 years and above.

Translation, reliability, and validity of the Brazilian-Portuguese version of the Brachial Plexus Outcome Measure scale (BPOM-Br)

Purpose To translate and investigate inter-rater reliability, internal consistency, content validity, and construct validity of the Brazilian-Portuguese Version of the Brachial Plexus Outcome Measure Scale (BPOM-Br). Material and methods The translation followed international guidelines. Inter-rater reliability was tested with 51 individuals with Neonatal Brachial Plexus Palsy (NBPP), aged between 4 to 16 years old. To determine concurrent construct validity, children were also assessed with the Mallet Scale. Statistical analysis included Bland-Altman, Intraclass Correlation Coefficient (ICC), Floor and Ceiling and effect, and Pearson correlation. Results The majority of the sample consisted of children with upper NBPP (75.2%), mean age of 8.9 years old. BPOM-Br showed appropriate content validity (comprehensiveness) according to rehabilitation professionals. It also showed excellent inter-rater reliability (ICC = 0.90) and internal consistency (α = 0.91). Bland-Altman analysis showed bias close to zero. Finally, BPOM-Br showed overall significant positive correlations with the Mallet scale items (rs= 0.31 to 0.78 p < 0.05), indicating adequate concurrent validity. Conclusions BPOM-Br is a consistent, reliable, and valid instrument to assess activity of school-aged children with NBPP. IMPLICATIONS FOR REHABILITATION The Brazilian-Portuguese Version of the Brachial Plexus Outcome Measure Scale (BPOM-Br) presents understandable items and no ceiling and floor effects. The BPOM-Br provides a valid and reliable version for use in Brazilian school-aged children with neonatal brachial plexus palsy. It is important to promote its use both in clinical practice and in research as a specific evaluation of activity domain.

“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 rehabilitation The 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.

Activity-based hand-function profile in preschool children with obstetric brachial plexus palsy

Obstetric brachial plexus palsy (OBPP) leads to various hand-function disorders. The present study aimed to determine activity-based hand function profiles in preschool children with different OBPP functional levels. 112 children aged 44–77 months were included, and grouped on the Narakas classification: group 1, Narakas type 1; group 2, type 2: and group 3, types 3 + 4. Hand function was evaluated on the Raimondi scale, stereognosis, and the elbow/forearm and wrist/finger/thumb sections of Brachial Plexus Outcome Measure (BPOM). Groups 1 and 2 successfully and comparably completed the BPOM hand activities (p > 0.05), while Group 1 had better results than Group 2 for BPOM elbow/forearm activities (p < 0.001): Group 2 had difficulty in activities involving elbow flexion, supination and pronation, whereas Group 1 had difficulty only in activities involving supination. Comparatively, Group 3 had lower scores for Raimondi scale (p < 0.001), BPOM-hand (p < 0.001), BPOM-elbow/forearm (p < 0.001) and stereognosis (p < 0.001). According to the literature, hand functions are conserved in upper-root brachial plexus injury and there is no need to evaluate them, but our results showed activity restrictions related to hand functions involving forearm rotation. In children with total plexus injury, grasp was absent and thumb function was deficient. The present showed that these restrictions can be identified by population-specific activity-based assessment.

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

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. 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. 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. 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. Therapeutic IV.

Surgical Reconstruction of Isolated Upper Trunk Brachial Plexus Birth Injuries in the Presence of an Avulsed C5 or C6 Nerve Root.

Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk. We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment. Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement. In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Reconstruction of Isolated Upper Trunk Brachial Plexus Birth Injuries in the Presence of an Avulsed C5 or C6 Nerve Root.

Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk. We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment. Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement. In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Relative importance of factors affecting activity and upper extremity function in children with Narakas Group 2 brachial plexus birth palsy.

The aim of the study was to determine the differences in upper limb function and activity/participation levels between preschool children with Narakas Groups 2a and 2b obstetric brachial plexus injury; and to determine the significance level of the factors affecting upper limb functions in these patients. Sixty-seven children, aged 3 to 7, who had not had surgical intervention, were evaluated in terms of joint movements, modified Mallet classification, Raimondi hand classification, brachial plexus outcome measure, paediatric outcome data collection instrument and stereognosis. There were significant functional differences between the groups, in favour of Group 2a. The movements affecting total function of the upper limb were: hand to spine (p < 0.001), global abduction (p < 0.001) and hand to mouth (p < 0.001), in descending order of significance. Passive internal rotation was the most important passive joint movement affecting shoulder function (p < 0.001). The results of this study suggest that more emphasis should be placed on the shoulder internal rotation in treatment strategies.Level of evidence: III.

Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function.

Shoulder release and tendon transfer is frequently performed to address persistent weakness from neonatal brachial plexus palsy. Although postoperative improvements in motion are well described, associated deficits are poorly documented, and functional assessments are lacking. Loss of ability to reach midline can occur with surgery and may result in impairment. The purpose of this study was to comprehensively assess the gains, losses, functional changes, and patient-reported outcome associated with the authors' surgical approach. Consecutive patients undergoing surgery with 2-year follow-up were included (n = 30). Prospectively recorded assessments by therapists were reviewed. Changes were assessed by t test and Wilcoxon rank sum (p < 0.05). Active external rotation and abduction improved and internal rotation diminished. Aggregate modified Mallet score increased with improvements in all subscales, except that hand to spine was unchanged and hand to belly decreased. Functional assessment using the Brachial Plexus Outcome Measure revealed an increase of aggregate score, with no decline in any subscales. Improvements were in hand to back of head, forward overhead reach, holds plate with palm up, opening large container, and strings bead. Aggregate patient self-report of appearance and function increased (from 18 to 23). Loss of ability to reach midline occurred in three patients (10 percent) who had extended Erb or total palsy and preoperative limitations of internal rotation. Secondary reconstruction rebalances shoulder motion by increasing external rotation and abduction and reducing internal rotation. In this study, a conservative surgical approach results in overall improvement in task-based abilities and self-reported outcomes and preservation of internal rotation within a functional range. Therapeutic, IV.

Inter-Observer Reliability of Brachial Plexus Outcome Measure in Children with Brachial Plexus Palsy

Amac: Brakiyal pleksus felci olan hastalarin gunluk yasam aktivitelerini, klinik islevlerini degerlendirmek icin bircok olcek gelistirilmistir. “Brachial Plexus Outcome Measure-Brakial Pleksus Sonuc Olcumu”, 2012 yilinda Emily Ho tarafindan gelistirildi, aktivite ve kendini degerlendirme bilesenlerden olusan toplam 14 madde iceren bir olcektir. Calismamiz gozlemciler arasi guvenilirligi arastirmak ve hastalara klinikte uygulamayi amaclamaktadir. Gerec ve Yontemler: Demografik ve klinik veriler kaydedildi, “Brachial Plexus Outcome Measure-Brakial Pleksus Sonuc Olcumu” iki farkli degerlendirmeci tarafindan uygulandi. Gozlemciler arasi guvenilirlik Kappa istatistikleri kullanilarak yapildi. Bulgular: On sekiz kadin (% 37,5) toplam 48 hasta dahil edildi. Gozlemler arasi guvenilirlik mukemmeldi (kappa 0.93). Uyum istatistiklerinde, gozlemcilerin madde analizlerinin ilimli (kappa 0.57) oldugu goruldu. Sonuc: “Brachial Plexus Outcome Measure-Brakial Pleksus Sonuc Olcumu”, Turkiye'de brakiyal pleksus felci olan cocuklarda fonksiyonlarin degerlendirilmesi icin guvenilir bir olcumdur. Klinik kullanimi uygundur.

Inter- and intra-rater reliability and clinical utility of the Brachial Plexus Outcome Measure: A pilot study

IntroductionBirth-related plexus injuries cause paralysis of the upper limb. The majority of patients spontaneously recover, but many suffer with long-term limitations in function. The Brachial Ple...

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

Study DesignClinical measurement and cross-sectional study. IntroductionNumerous scales have been developed to examine activities of daily living and function in children with brachial plexus palsy. The Brachial Plexus Outcome Measure (BPOM) scale was developed in 2012 by Emily S. Ho and contains 14 items that measure activity and self-evaluation. Purpose of the StudyThe aim of the study was to cross-culturally translate the BPOM scale into Turkish and test its measurement properties in children with brachial plexus palsy. MethodsThe scale was translated into Turkish using standard cross-cultural translation procedures. Forty-eight children with obstetric brachial plexus palsy (OBPP) were included in psychometric evaluations. Internal structure consistency and test-retest reliability were measured for reliability analyses. For each item on the scale, Cronbach alpha coefficient and item-total score correlations for all subscales were calculated. The scale was administered at baseline and 1 week later by 2 different physiotherapists to evaluate test-retest reliability. Concurrent construct validity was assessed using Pearson correlations between the OBPP and the Mallet classification system. ResultsEighteen (37.5%) girls and 30 (62%) boys, in total 48 children, whose mean age was 8.7 ± 2.4 (minimum-maximum = 5-14) years were included in the study; 9 (18.9%) have a history of both early microsurgery and tendon transfers and 39 (81.3%) have a history of only tendon transfer. Cronbach alpha ranged from 0.89 to 0.96, and for the whole scale, it was calculated as 0.938. DiscussionTest-retest reliability was high. Moderate correlations were observed between the measures. ConclusionThe Turkish BPOM scale is a valid and reliable measurement for assessing function in children with OBPP in the Turkish population.

Forearm Pronation Osteotomy for Supination Contracture Secondary to Obstetrical Brachial Plexus Palsy: A Retrospective Cohort Study.

Obstetrical brachial plexus palsy can lead to fixed forearm supination contracture. Fixed supination may lead to functional deficits as the affected hand cannot be positioned optimally for activities on a desk such as writing and typing, or for using tools including utensils, which require a neutral or pronated forearm. Forearm pronation osteotomy has been used to address this problem, although the functional benefit over nonoperative management has not been clearly defined. Potentially deleterious consequences on hand function that requires supination or fine motor skills are also uncertain. Patients with fixed forearm supination contracture were selected from our institutional brachial plexus database. Those who underwent both bone forearm rotational osteotomy were analyzed for age at time of surgery, preoperative forearm resting position, active and passive supination and pronation, and preoperative function assessed by the brachial plexus outcome measure (BPOM) and active movement scale (AMS). Preoperative results were compared with values obtained at follow-up at least 12 months postoperatively. A matched cohort of children with fixed forearm supination contracture that were treated nonoperatively and followed for at least 12 months, was also selected. For this group, forearm resting position, movement, AMS, and BPOM scores were analyzed at a baseline clinic visit and the most recent follow-up. Changes in forearm resting position, AMS, and BPOM activity scale scores were then compared between groups. Records were obtained for 14 cases and 10 controls. Study groups were similar with respect to resting forearm position, hand function, and time from initial to final evaluation. Groups differed with respect to age and active supination. We observed a statistically significant change in resting position among operative patients compared with their preoperative status and compared with controls. Hand-specific AMS score did not change significantly in the operative group as compared with controls. The BPOM score for drums, reflective of function in neutral rotation to mild pronation, improved in the operated patients as compared with controls. There was no loss of plate holding ability (reflective of supination function, putty (grasp), or bead placement (fine motor) among the operated patients as compared with controls. By pronating resting forearm position by about 90 degrees to near neutral, osteotomy resulted in improved neutral to mild pronation-dependent function without loss of supination-dependent function or hand motor skills. Level III-retrospective cohort study.

Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline

ObjectiveThe objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing...

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