Search

Background: Neonatal brachial plexus palsy (NBPP) results in muscle weakness and impaired somatosensory function of the arm. Current functional assessment is primarily based on clinician‐elicited measurements including muscle strength and range of motion. To what extent these measures are representative of real‐world arm movement is unclear. Objective: To determine the feasibility of using body‐worn accelerometers to remotely assess arm movements in children with NBPP. Design Prospective criterion validity study of accelerometry versus clinician assessment. Setting: Academic medical center. Participants: Nine adolescents with NBPP and nine age‐ and gender‐matched control adolescents participated in the study. All were enrolled in school and participated in community activities. Interventions: Not applicable. Methods: Standard clinician‐elicited measurements were collected. For assessing spontaneous arm movements, participants wore activity monitors during all waking hours for 7 days. Results were expressed as ratios of affected to unaffected arm motion for duration and magnitude and correlated with traditional clinic‐based assessments. Spearman correlations were used to determine relationships between accelerometry results and traditional assessments. A p value <.05 was considered statistically significant. Main Outcome Measurements Accelerometry measurements of arm motion and traditional clinical assessments. Results: Compared to control ratios, duration of arm movement and magnitude ratios were reduced in the NBPP group, particularly for arm magnitude due to reduced affected arm movement and an increase in unaffected arm movement. Ratios were highly correlated with shoulder function and, to a lesser extent, with elbow function. Conclusion: Real‐world arm use is an appropriate outcome measure that reflects functional recovery. This study demonstrates the feasibility of wearable technology to quantify duration and intensity of spontaneous arm movement in children with NBPP. Accelerometry also allows for the association between traditional clinician‐elicited assessment measures and spontaneous arm movements, demonstrating the importance of the shoulder as a focus of treatment in NBPP. [ABSTRACT FROM AUTHOR]

The prevalence of carpal tunnel syndrome (CTS) in patients with postpolio syndrome occurs at a rate of 22%. Irrespective of those with CTS, 74% of postpolio patients weight bear through their arms for ambulation or transfers. As open carpal tunnel release is performed along the weight-bearing region of the wrist, their functional independence may be altered while recovering. This case demonstrates that ultrasound-guided carpal tunnel release was successfully performed in a patient with postpolio syndrome allowing him to immediately weight bear through his hands after the procedure so he could recover at home. LEVEL OF EVIDENCE: V. [ABSTRACT FROM AUTHOR]

Background: The term self-determination refers to decision-making, goal setting, and perseverance to achieve those goals. Numerous studies have established the importance of self-determination to enhance learning and improve postschool outcomes. However, most studies evaluate students with learning disabilities, cognitive impairment, or behavioral disabilities. There is an absence of research on self-determination for adolescents with physical disabilities.Objective: To assess self-determination of adolescents with neonatal brachial plexus palsy (NBPP) compared with their typically developing peers via self-reported measures of function.Design: Case-control study.Setting: Brachial plexus clinic.Participants: Twenty adolescents with NBPP (aged 10-17 years) and their parents and 20 age/gender-matched typically developing adolescents and their parents were recruited. Non-English-speaking participants and those with other physical impairments were excluded from study.Methods: Participants completed demographic and American Institutes for Research (AIR) self-determination surveys. One of two designated occupational therapists evaluated participant physical function.Main Outcome Measurements: A demographic survey and AIR self-determination assessment were administered, and active range of motion measurements in shoulder forward flexion, elbow flexion, elbow extension, forearm pronation, and supination were obtained. Grip/pinch strength, MRC muscle strength, 9-Hole Peg Test, and Mallet scale scores also were evaluated.Results: Despite physical differences, adolescents with NBPP presented similar self-determination levels as their typically developing peers. Adolescents with NBPP rated their opportunities to engage in self-determined behaviors at school significantly lower than at home. Both adolescents with NBPP and those in the control group rated their opportunities to engage in self-determined behaviors at school significantly lower than at home.Conclusions: Adolescents with NBPP presented similar self-determination scores as their age/gender-matched typically developing peers. These results could be a reflection of our program's patient- and family-centered care approach. Therefore, caregivers and providers should encourage personal development and fulfillment in adolescents with NBPP. Teachers and schools should be aware that opportunities for acquiring self-determination skills might be more limited at school than at home in this age group.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Background: Currently, no published, validated patient-reported outcome (PRO) measures of health-related quality of life (HRQOL) exist for use with neonatal brachial plexus palsy (NBPP). NBPP is a debilitating condition that occurs during the perinatal period, resulting in paralysis/paresis and loss of sensation in the affected arm. Commonly used NBPP measures are not comprehensive and do not fully account for clinically meaningful changes in function or progression of the disorder.Objective: To evaluate important components of HRQOL for children with NBPP and identify where new PRO measures are needed.Design: Eleven focus groups comprising children with NBPP (4), family members (6), and professional providers (1) to assess HRQOL.Setting: Brachial plexus clinic.Participants: Children with NBPP, their parents, and professional providers.Inclusion Criteria: Children 7-17 years old with NBPP; parents/caregivers at least 18 years of age; professionals with ≥2 years' experience providing NBPP clinical care; ability to read and speak English fluently.Methods: Focus group sessions were recorded, transcribed verbatim, and deidentified. Qualitative frequency analysis identified different aspects of HRQOL relevant to NBPP. This analysis expands on the grounded-theory approach to qualitative analysis, including development of a domain framework, open and axial coding, selective coding, and descriptive analysis. The resulting HRQOL domain framework (and frequency analysis) was then compared to the domain framework for existing PRO measures (PROMIS and Neuro-QoL) to identify components of HRQOL where new PRO measures are needed for NBPP.Main Outcome Measures: Not applicable.Results: Although many physical, social, and emotional health domains were captured by existing PRO measures, some significant NBPP-specific topics emerged from qualitative analysis-functionality, sensory, physical appearance, arm/hand compensation and preference, explaining functionality/appearance to others, and self-esteem and body image concerns.Conclusions: Development of sensitive and specific measures capturing arm/hand function and body image would improve the clinical care of patients with NBPP.Level Of Evidence: Not applicable. [ABSTRACT FROM AUTHOR]

A motorcyclist sustained multiple-system trauma, including a left buttock hematoma requiring decompression and evacuation. Presentation for severe hip pain and lower extremity weakness was delayed. Imaging revealed myositis ossificans traumatica compressing the sciatic nerve in the buttock. The patient underwent sciatic nerve decompression with resection of heterotopic calcification, resulting in improvement in pain and left lower extremity function. This case illustrates the contrast in differential diagnosis of peripheral nerve injury immediately posttrauma and that occurring in a slow, delayed fashion posttrauma. Myositis ossificans may be an underrecognized complication of trauma but should be considered in cases of delayed peripheral nerve injury after trauma. [ABSTRACT FROM AUTHOR]

Background: Children with neonatal brachial plexus palsy (NBPP) are often prescribed shoulder range of motion (ROM) exercises; however, the extent and timing of exercise implementation remains controversial in the context of shoulder joint integrity. The association of ROM exercises to delayed posterior shoulder subluxation (PSS) is unknown.Objective: To determine prevalence of PSS in children with NBPP who began full passive ROM exercises before 6 months of age, and characteristics associated with development or absence of PSS in children.Design: Cross-sectional study.Setting: Tertiary care NBPP referral center.Participants: Forty-six children with NBPP, aged 24-57 months, who began full ROM exercises before 6 months of age.Methods: One radiologist conducted bilateral shoulder ultrasound (US) on each child to evaluate for PSS. One occupational therapist evaluated each child clinically for PSS using defined parameters without knowledge of US results.Main Outcome Measures: By US, 20% of children had PSS; 46% had PSS by clinical examination. Shoulder active ROM limitations and history of shoulder surgery were associated with presence of PSS. Extent of NBPP was not associated with PSS.Results: Nine of 46 children (20%) met US criteria for PSS; α angle was 58° ± 21° (mean ± standard deviation [SD]). Twenty-one children (46%) met clinical criteria. Mean age at examination was 35 ± 10 months. Shoulder active ROM (P ≤ .004) was associated with PSS, whereas passive ROM was not (P ≥ .08). History of secondary shoulder surgery and primary nerve graft repair were associated with PSS (P = .04). Extent of NBPP by Narakas classification was not associated with PSS (P = .48).Conclusions: Early use of full-arc passive ROM home exercise program is not associated with increased prevalence of PSS in children with NBPP compared to prevalence of PSS in published literature. We suggest careful clinical examination, based on defined criteria, provides a reasonable screening examination for evaluating PSS that can be confirmed by noninvasive US. [ABSTRACT FROM AUTHOR]

Study design: Case report. Introduction: The value of movement-based therapy in peripheral nerve injury conditions such as neonatal brachial plexus palsy (NBPP) is unclear. Purpose of the study: To determine the effectiveness of a home-based movement therapy program in a 17 year old female patient with a right NBPP pan-plexopathy. Methods: Home training consisted of arm reaching and object manipulation tasks using devices which recorded performance. Tiaining occurred for 1 h/day, 5 days/week for 6 weeks with periodic webcam supervision. Pre- and post clinical, functional and kinematic assessments were performed in a laboratory setting. Results: Following training, shoulder flexion and elbow extension active range of motion increased by 13° and 9°, respectively, and functional ability also improved. Reach movement duration decreased significantly with a concomitant improvement in movement coordination. Conclusions: These results demonstrate that movement therapy has the potential to improve motor function in NBPP years after the initial insult. [ABSTRACT FROM AUTHOR]

Abstract: Successful treatment of patients with neonatal brachial plexus palsy (NBPP) begins with a thorough understanding of the anatomy of the brachial plexus and of the pathophysiology of nerve injury via which the brachial plexus nerves stretched in the perinatal period manifest as a weak or paralyzed upper extremity in the newborn. NBPP can be classified by systems that can guide the prognosis and the management as these systems are based on the extent and severity of nerve injury, anatomy of nerve injury, and clinical presentation. Serial physical examinations, supplemented by a thorough maternal and perinatal history, are critical to the formulation of the treatment plan that relies upon occupational/physical therapy and rehabilitation management but may include nerve reconstruction and secondary musculoskeletal surgeries. Adjunctive imaging and electrodiagnostic studies provide additional information to guide prognosis and treatment. As research improves not only the technical aspects of NBPP treatment but also the ability to assess the activity and participation as well as body structure and function of NBPP patients, the functional outcomes for affected infants have an overall optimistic prognosis, with the majority recovering adequate functional use of the affected arm. Of importance are (i) early referral to interdisciplinary specialty clinics that can provide up-to-date advances in clinical care and (ii) increasing research/awareness of the psychosocial and patient-reported quality-of-life issues that surround the chronic disablement of NBPP. [Copyright &y& Elsevier]

Abstract: Objective: To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE). Design: Prospective cohort followed for 1 year. Setting: Clinics. Participants: Patients diagnosed with UNE (N=55). Intervention: All subjects had simple decompression surgery. Main Outcome Measures: The primary outcome measure was patient-reported outcomes, such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow. Results: Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with <3 months duration of symptoms showed 12 points (95% confidence interval [CI], 0.9–23.5) greater improvement in MHQ scores than those with ≥3 months symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI, 2.9–24) greater improvement in MHQ scores at 6 months postoperative, but it was no longer associated with better outcomes at 12 months. A worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coefficient, −0.38; 95% CI, −.67 to −.09), and baseline MHQ score was the only significant predictor of 12 month MHQ scores (coefficient, −.40; 95% CI, −.79 to −.01). Conclusions: Subjects with <3 months of symptoms and worse baseline MHQ scores showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery. [Copyright &y& Elsevier]

Objective: To evaluate the accuracy of home exercise performance by caregivers of children with neonatal brachial plexus palsy (NBPP) who use digital versatile disc (DVD) guidance. Design: Prospective cohort study. Setting: Brachial Plexus Clinic at the University of Michigan. Participants: Seventy-six adult caregivers of a consecutive cohort of pediatric patients with NBPP. Methods: Caregivers received the Home Exercise Program for Brachial Plexus Palsy DVD and an initial demonstration of correct hand placement and movement patterns by 1 of 2 occupational therapists. At times A, B, and C (approximately 3, 6, and 12 months), caregiver accuracy in exercise performance at each joint and standard measurements of arm function were recorded. Main Outcome Measurements: Caregiver accuracy in correct hand placement and movement pattern during exercise performance was evaluated with use of a dichotomy scale (yes/no) at each joint. Active and passive range of motion were assessed as indicators of arm function. Results: The mean patient age was 38 months, and the median Narakas score was 2. No significant difference in exercise accuracy for all upper extremity joints between the initial evaluation and times A, B, and C or between individual times was observed, except at the shoulder (98.9% initially to 88.3% at time A; P = .0002) and elbow (100% initially to 96.6% at time A; P = .04). Regarding arm function, an increase in active range of motion for shoulder flexion, elbow flexion, forearm supination, wrist extension, and finger flexion was observed during the study period. Conclusions: Shoulder and elbow exercises may be more complex, requiring more frequent performance review with the caregiver. However, the home exercise DVD may benefit patients with NBPP and their caregivers and may provide an adjunct to formal therapy sessions. [Copyright &y& Elsevier]

Abstract: Triolo RJ, Bailey SN, Miller ME, Rohde LM, Anderson JS, Davis JA Jr, Abbas JJ, DiPonio LA, Forrest GP, Gater DR Jr, Yang LJ. Longitudinal performance of a surgically implanted neuroprosthesis for lower-extremity exercise, standing, and transfers after spinal cord injury. Objective: To investigate the longitudinal performance of a surgically implanted neuroprosthesis for lower-extremity exercise, standing, and transfers after spinal cord injury. Design: Case series. Setting: Research or outpatient physical therapy departments of 4 academic hospitals. Participants: Subjects (N=15) with thoracic or low cervical level spinal cord injuries who had received the 8-channel neuroprosthesis for exercise and standing. Intervention: After completing rehabilitation with the device, the subjects were discharged to unrestricted home use of the system. A series of assessments were performed before discharge and at a follow-up appointment approximately 1 year later. Main Outcome Measures: Neuroprosthesis usage, maximum standing time, body weight support, knee strength, knee fatigue index, electrode stability, and component survivability. Results: Levels of maximum standing time, body weight support, knee strength, and knee fatigue index were not statistically different from discharge to follow-up (P>.05). Additionally, neuroprosthesis usage was consistent with subjects choosing to use the system on approximately half of the days during each monitoring period. Although the number of hours using the neuroprosthesis remained constant, subjects shifted their usage to more functional standing versus more maintenance exercise, suggesting that the subjects incorporated the neuroprosthesis into their lives. Safety and reliability of the system were demonstrated by electrode stability and a high component survivability rate (>90%). Conclusions: This group of 15 subjects is the largest cohort of implanted lower-extremity neuroprosthetic exercise and standing system users. The safety and efficiency data from this group, and acceptance of the neuroprosthesis as demonstrated by continued usage, indicate that future efforts toward commercialization of a similar device may be warranted. [Copyright &y& Elsevier]

Objective: To investigate the impact of a video-based educational resource on home exercise compliance among caregivers of children with neonatal brachial plexus palsy (NBPP). Design: Retrospective analysis of self-reported caregiver home exercise habits and resultant shoulder range of motion (ROM) and biceps power in patients with NBPP. Setting: Home-based exercise program. Participants: Adult caregivers of children with NBPP followed up through the Brachial Plexus Program at the University of Michigan (N = 83 surveyed initially, with N = 37 completing the final survey). Methods: Caregivers completed surveys before and approximately 3, 6, and 12 months (times A, B, and C, respectively) after receiving the “Home Exercise Therapy Program for Brachial Plexus Palsy” digital video disk (DVD). A retrospective analysis of shoulder ROM and biceps power of patients was completed as representative of arm function during the study. Main Outcome Measurements: Surveys assessed home exercise compliance, resources used to guide exercises, and caregiver confidence in the correctness of exercises being performed. Functional outcomes analyzed include biceps strength and shoulder active and passive ROM. Results: Home exercise compliance increased from 74% initially to 96% at time A (P < .001), remained at 94% at time B (P < .001), and fell to 84% at time C (P = .016). Use of the DVD to guide home exercise decreased from 69% at time A to 57% at time B and C (P = .026). After receiving the DVD, exercise frequency and caregiver confidence increased. Although some measures of shoulder active ROM and biceps power improved during the course of the study, there was no consistent statistically significant relationship between increased caregiver confidence and functional outcomes. No causal relationship exists between DVD content and functional status at this time. Conclusions: As the first formal evaluation of a video-based resource guiding exercise therapy for children with NBPP, we suggest that this population may be receptive to alternative media and may benefit from dynamic modeling of home exercises. [ABSTRACT FROM AUTHOR]

Objective: To increase awareness of the advancements in nerve regeneration. Methods: Review of the literature regarding inhibitors of nerve outgrowth and presentation of potential agents that reverse the inhibition, thereby promoting nerve regeneration. Results: The injured adult central nervous system (CNS) inhibits axon outgrowth, thereby limiting recovery from traumatic injury. Axon regeneration inhibitors (ARIs) that contribute to inhibition of recovery include myelin-associated glycoprotein, Nogo, oligodendrocyte-myelin glycoprotein and chondroitin sulfate proteoglycans. The ARIs bind to specific receptors on the axon growth cone to halt outgrowth; consequently, reversing or blocking the actions of ARIs may promote recovery after CNS injury. Sialidase, an enzyme that cleaves one class of axonal receptors for myelin-associated glycoprotein, enhances spinal axon outgrowth into implanted peripheral nerve grafts in a rat model of brachial plexus avulsion, a traumatic injury in which nerve roots are torn from the spinal cord. Conclusion: Repair using peripheral nerve grafts is a promising restorative surgical treatment in humans, although functional improvement remains limited. Molecular therapies targeting ARIs may aid functional recovery after brachial plexus avulsion or other nervous system injuries and diseases. [ABSTRACT FROM AUTHOR]