The aim of this thesis was to gain a better understanding of the deleterious effects of Neonatal Brachial Plexus Palsy (NBPP) on central development by analyzing sensory and motor function.The... Show moreThe aim of this thesis was to gain a better understanding of the deleterious effects of Neonatal Brachial Plexus Palsy (NBPP) on central development by analyzing sensory and motor function.The explanation for problems with hand function was not clear in children who had an upper NBPP where only the C5 and C6 spinal nerves are affected, which predominantly innervate the shoulder and elbow flexion. The main findings of this thesis: Children with an upper NBPP have a diminished sensibility of the thumb and index finger which correlates with diminished dexterity. The ability to localize stimuli to the thumb, index, third and fourth fingers is disturbed in children with an upper NBPP. Most children with an upper NBPP are not aware of the diminished sensibility in their affected hand. Also Grip force of the hand is reduced in children with an upper NBPP lesion. NBPP is a peripheral nervous lesion, which affects the development of the central nervous system as well. The age at which children with NBPP can walk independently is delayed, which does not depend on the severity of the lesion. Treatment of children with a NBPP had to focus on the total development of the child. Show less
Objective: To investigate factors that cause impairment of hand function in children with an upper Neonatal Brachial Plexus Palsy (NBPP), we performed an in-depth analysis of tactile hand... Show moreObjective: To investigate factors that cause impairment of hand function in children with an upper Neonatal Brachial Plexus Palsy (NBPP), we performed an in-depth analysis of tactile hand sensibility, especially the ability to correctly localize a sensory stimulus on their fingers.Design: A cross-sectional investigation of children with NBPP, compared with healthy controls. The thickest Semmes-Weinstein (SW) monofila-ment was pressed on the radial or ulnar part of each fingertip (10 regions), while a screen prevented seeing the hand.Setting: Tertiary referral center for nerve lesions in an academic hospital in The Netherlands. The control group was recruited at their school.Participants: Forty-one children with NBPP (mean age 10.0 y) and 25 controls (mean age 9.5 y; N=41). Interventions: Not applicable.Main Outcomes Measures: Correct localization of the applied stimuli was evaluated, per region, per finger, and per dermatome with a test score. The affected side of the NBPP group was compared with the non-dominant hand of the controls.Results: The ability to localize stimuli on the tips of the fingers in children with an upper NBPP was significantly diminished in all fingers, except for the little finger, as compared with healthy controls. Mean localization scores were 6.6 (thumb) and 6.3 (index finger) in the NBPP group and 7.6 in both fingers for controls (maximum score possible is 8.0). Localization scores were significant lower in regions attributed to dermatomes C6 (P<.001) and C7 (P=.001), but not to C8 (P=.115).Conclusion: Children with an upper NBPP showed a diminished and incorrect ability to localize sensory stimuli to their fingers. This finding is likely 1 of the factors underlying the impairment of hand function and should be addressed with sensory focused therapy. Archives of Physical Medicine and Rehabilitation 2023;104:872-7 & COPY; 2022 by the American Congress of Rehabilitation Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Show less
Objective: To assess gripforce in children with a C5 and C6 neonatal brachial plexus palsy, as it may affect hand use. Applying classic innervation patterns, gripforce should not be affected, as... Show moreObjective: To assess gripforce in children with a C5 and C6 neonatal brachial plexus palsy, as it may affect hand use. Applying classic innervation patterns, gripforce should not be affected, as hand function is not innervated by C5 or C6. This study compares gripforce in children with a neonatal brachial plexus palsy with that in a healthy control group, and assesses correlations with hand sensibility, bimanual use and external rotation.Methods: A total of 50 children with neonatal brachial plexus palsy (mean age 9.8 years) and 25 controls (mean age 9.6 years) were investigated. Nerve surgery had been performed in 30 children, and 20 children had been treated conservatively. Gripforce of both hands was assessed using a Jamar dynamometer. Sensibility of the hands was assessed with 2-point discrimination and Semmes-Weinstein monofilaments. External rotation was assessed using the Mallet score. Bimanual use was measured by using 1 of 3 dexterity items of the Movement Assessment Battery for Children-2. The affected side of the neonatal brachial plexus palsy group was compared with the non-dominant hand of the control group using 1-way analysis of variance (ANOVA), x(2) and Mann-Whitney tests.Results: The mean gripforce of the affected non-dominant hand of children with neonatal brachial plexus palsy was reduced compared with healthy controls (95 N and 123 N, respectively, with p = 0.001). The mean gripforce of the non-dominant hand in the control group was 92% of that of the dominant hand, while it was only 76% in the neonatal brachial plexus palsy group (p =0.04). There was no relationship between gripforce reduction and sensibility, bimanual use or shoulder external rotation.Discussion: The gripforce in neonatal brachial plexus palsy infants with a C5 and C6 lesion is lower than that of healthy controls, although classic interpretation of upper limb innervation excludes this finding. The reduction in gripforce in upper neonatal brachial plexus palsy lesions is not widely appreciated as a factor inherently compromising hand use. The reduction in gripforce should be taken into consideration in planning the type of rehabilitation and future activities. Show less
Background Obstetric brachial plexus injuries result from traction injuries during delivery, and 30% of these children have persisting functional limitations related to an external rotation deficit... Show moreBackground Obstetric brachial plexus injuries result from traction injuries during delivery, and 30% of these children have persisting functional limitations related to an external rotation deficit of the shoulder. Little is known about the long-term effect of soft-tissue procedures of the shoulder in patients with obstetric brachial plexus injuries. Questions/purposes (1) After soft-tissue release for patients with passive external rotation less than 20 degrees and age younger than 2 years and for patients older than 2 years with good external rotation strength, what are the improvements in passive external rotation and abduction arcs at 1 and 5 years? (2) For patients who underwent staged tendon transfer after soft-tissue release, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? (3) For patients with passive external rotation less than 20 degrees and no active external rotation, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? Methods This was a retrospective analysis of a longitudinally maintained institutional database. Between 1996 and 2009, 149 children underwent a soft-tissue procedure of the shoulder for an internal rotation contracture. The inclusion criteria were treatment with an internal contracture release and/or tendon transfer, a maximum age of 18 years at the time of surgery, and a minimum follow-up period of 2 years. Six patients were older than 18 years at the time of surgery and 31 children were seen at our clinic until 1 year postoperatively, but because they had good clinical results and lived far away from our center, these children were discharged to physical therapists in their hometown for annual follow-up. Thus, 112 children (59 boys) were available for analysis. Patients with passive external rotation less than 20 degrees and age younger than 2 years and patients older than 2 years with good external rotation strength received soft-tissue release only (n = 37). Of these patients, 17 children did not have adequate active external rotation, and second-stage tendon transfer surgery was performed. For patients with passive external rotation less than 20 degrees with no active external rotation, single-stage contracture release with tendon transfer was performed (n = 68). When no contracture was present (greater than 20 degrees of external rotation) but the patient had an active deficit (n = 7), tendon transfer alone was performed; this group was not analyzed. A functional assessment of the shoulder was performed preoperatively and postoperatively at 6 weeks, 3 months, and annually thereafter and included abduction, external rotation in adduction and abduction, and the Mallet scale. Results Internal contracture release resulted in an improvement in passive external rotation in adduction and abduction of 29 degrees (95% confidence interval, 21 to 38; p < 0.001) and 17 degrees (95% CI, 10 to 24; p < 0.001) at 1 year of follow-up and 25 degrees (95% CI, 15-35; p < 0.001) and 15 degrees (95% CI, 7 to 24; p = 0.001) at 5 years. Because of insufficient strength of the external rotators after release, 46% of the children (17 of 37) underwent an additional tendon transfer for active external rotation, resulting in an improvement in active external rotation in adduction and abduction at each successive follow-up visit. Patients with staged transfers had improved active function; improvements in active external rotation in adduction and abduction were 49 degrees (95% CI, 28 to 69; p < 0.05) and 45 degrees (95% CI, 11 to 79; p < 0.001) at 1 year of follow-up and 38 degrees (95% CI, 19 to 58; p < 0.05) and 23 degrees (95% CI, -8 to 55; p < 0.001) at 5 years. In patients starting with less than 20 degrees of passive external rotation and no active external rotation, after single-stage contracture release and tendon transfer, active ROM was improved. Active external rotation in adduction and abduction were 75 degrees (95% CI, 66 to 84; p < 0.001) and 50 degrees (95% CI, 43 to 57; p < 0.001) at 1 year of follow-up and 65 degrees (95% CI, 50 to 79; p < 0.001) and 40 degrees (95% CI, 28 to 52; p < 0.001) at 5 years. Conclusion Young children with obstetric brachial plexus injuries who have internal rotation contractures may benefit from soft-tissue release. When active external rotation is lacking, soft-tissue release combined with tendon transfer improved active external rotation in this small series. Future studies on the degree of glenohumeral deformities and functional outcome might give more insight into the level of increase in external rotation. Show less
