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Brachial Plexus 1
Brachial Plexus 1
Brachial Plexus 1
MANAGEMENT
OF obstetric brachial
plexus injury
Definition:
The brachial plexus is a network of nerves that conducts signals from
the spine to upper extremities. Brachial Plexus Injuries (BPI) are
caused by damage to those nerves. Many BPI occur during birth; the
baby’s shoulders may become impacted during the birth process
causing the brachial plexus nerves to stretch or tear. There are different
types of BPI:
Ref( 3 )
Time of intervention:
The rehabilitation of children with BPI must begin as soon as the injury
is recognized in the newborn nursery during the first week of life and
should continue up to school aged children (4 years).
Rehabilitation stages:
Stage 1 First 2 weeks
Stage 2 From 2 weeks – 4 months
Stage 3 From 4 months to 6 months
Stage 4 From 6 months to 1 year
Stage 5 From 1 year to 4 years
Goals:
1. To educate caregiver in handling, positioning, and daily living
activities.
2. To Improve/ maintain Range of Motion (ROM).
3. To improve/maintain muscle strength.
4. To improve sensation (where appropriate).
5. To gain milestones and age appropriate skills.
6. To prevent joint contracture and deformities.
Assessment:
The mother or caregiver should attend all sessions to learn from the
physical therapist and to implement appropriate positioning and
handling techniques at home. Assessment should be completed with in
the first 3 sessions with the affected arm undressed in warm
environment, whether in the side lying or supine positions to eliminate
gravity and to allow free movement of the arm (Appendix A).
Precautions:
Treatment:
(Fig1) (Fig2)
• Do not let the arm dangle in space while carrying the child (Fig3).
The parent can keep the elbow flexed and on top of the chest but
not for long periods of time (Fig4).
(Fig3) (Fig4)
• Teach parents proper way of wrapping (Fig.5).
(Fig5)
• Dressing: for dressing, start with the affected arm and for
undressing start with the unaffected arm.
• Bathing and hygiene: instruct the mother to keep the armpit
always dry and clean. In bathing, support the affected
shoulder and scapula with one hand and wash the baby with
the free hand.
• Feeding: always keep the affected arm flexed on the baby’s
chest while feeding him, and remind the mother to feed the
baby from both sides.
(Fig6) (Fig7)
(Fig8)
(Fig9)
(Fig12) (Fig13)
3. Although the use of electrical stimulation (ES) is controversial
and it’s effectiveness has not been adequately tested, it can be
used if there is poor prognosis (from 6th month) with Galvanic
type of ES for 15 repetitions to prevent muscle atrophy and to
increase limb awareness Ref(1 ). On the other hand,
Functional Electrical Stimulation (FES) is increasingly used in
neurological rehabilitation to improve mobility and upper limb
function. FES is a means of producing functional movement in
paralyzed muscles by the application of electrical impulses to
the nerves of those muscles and it should be applied for 30
minutes daily during the treatment period. FES improves hand
function, active wrist extension, weight bearing with the
impaired upper limb, increases awareness and spontaneous
use of the impaired limb and improves hand grasp and release
abilities Ref(4 ).
4. Hydrotherapy:
It can be introduced at this stage to prevent muscle tightness,
muscle control, improve joint ROM besides being fun for the child.
Complications:
1. Scapula winging.
2. Torticolus.
3. Midline Asymmetry.
4. Postural scoliosis.
5. limb length discrepancy
Appendix (B)
Classification of Brachial Plexus Injuries according to predict
outcomes (Clarke & Curtis -1995)
Points to Remember
Do not use weights on the affected limb during the first stage of weight
bearing activities
Three point elbow To make with an adjustable elbow extension pull for an
extension splint elbow flexion contracture.
Elbow conformer Used for soft tissue contracture caused by elbow flexors
splint overpowering extensors. To maintains the arm in
extension for active reaching, to strengthen deltoid or in
weight bearing activities.
Dynamic elbow Used when there is no active elbow flexion just full
flexion splint extension.
Joe cool splint To increase active thumb abduction and opposition after 3-
4 months of age.
Air splint To allow stability in elbow extension for weight bearing in
crawling and for reaching, also used to immobilize
unaffected arm to allow affected arm to move actively with
assistance.
References:
3. www.obgyn.net/pb/articles/dystocia-casereport.htm
4. www.salisburyfes.com
5. www.membrane.com/bpp/protocol