Rehabilitation in Neonatal Brachial Plexus Palsy

11 Aug 2017 Pariya Wimonwattrawatee, MD.

การฟนฟสมรรถภาพผปวยNeonatal Brachial Plexus Palsy

(Rehabilitation in NBPP)

Role of Rehabilitation

Prevent further injury

Prevent complication

Strengthen recovering muscles

Achieve developmental milestones

Age appropriate functional use

Electrodiagnosis

Prevent Further Injury

Mechanism: traction injury

Incomplete injury

Mobilization – painful

Immolization shoulder 7-15 days

Elbow to the body

80-92% = spontaneous resolve

2 months

50-66% = complete recovery

Anti-gravity biceps strength in 2 months

Full & complete recovery over 1 -2 years Narakas AO, et al. Orthopade 1987

Long-term limb immobilization

Associated with shoulder deformity

Except fractures

Prevent Further Injury

Clavicle fracture

Humerus fracture

Bilateral NBPP

Associated fracture

Muscle atrophy

Limited range of motion / contracture

Shoulder

Shoulder deformity

Glenoid retroversion

Posterior subluxation

Prevent Complication

Radial head subluxation

Compensatory movement

Injury to extremity (lack of sensation)

Torticollis

Muscle atrophy

Limited range of motion / contracture

Shoulder

Shoulder deformity

Glenoid retroversion

Posterior subluxation

Electrical Stimulation

Retard muscle atrophy

Preserve endplate

Limited ROM / Contracture

Classification (Narakas)

Group Neurological Signs Percentage

1: C5-6 lesion Paresis of deltoid & biceps m 46-60%

2: C5-7 lesion Paresis of shoulder & extension of elbow, wrist & finger

3: C5-8 (T1) lesion Paresis virtually complete with some finger flexion

4: Whole plexus involvement

Paresis of arm; Horner syndrome

Klumpke palsy <2%

Classification (Narakas)

Group Moro Active elbow flexion

Active wrist & hand

extension

Grasping reflex

1: C5-6 lesion X X / /

2: C5-7 lesion X X X /

3: C5-8 (T1) lesion X X X +/-

4: Whole plexus involvement

X X X X

Klumpke X / / X

Shoulder

Internal Rotator External Rotator

Muscle Root Muscle Root

Deltoid (anterior) C5, C6 Deltoid (posterior) C5, C6

Teres major C5, C6 Infraspinatus C5, C6

Subscapularis C5, C6 Teres minor C5, C6

Latissmus dorsi C6, C7, C8

Pectoralis major C5, C6, C7, C8, T1

Contracture: Internal Rotation

Pectoralis major / minor (C5-T1 roots)

Internal Rotation Contracture

Most frequent

Appear early and rapid

5 months

Responsible for growth problems of the glenohumeral joint

Shoulder

Adductor Abductor

Deltoid (anterior & posterior)

C5, C6 Deltoid (middle) C5, C6,

Infraspinatus C5, C6 Supraspinatus C5, C6

Teres major C5, C6

Coracobrachialis C5, C6, C7

Triceps (long head) C6, C7, C8

Latissimus dorsi C6, C7, C8

Pectoralis major C5, C6, C7, C8, T1

Contracture: Adduction

Shoulder Flexor

Muscle Root

Anterior Deltoid C5, C6

Biceps brachii C5, C6

Coracobrachialis C5, C6

Pectoralis Major C5, C6, C7, C8, T1

Only forward flexion < 90o

Contracture: Extension

Flexion Extension

Biceps brachii C5, C6 Triceps C6, C7, C8

Brachialis C5, C6 Anconeus C7, C8

Brachioradialis C5, C6

Supinator Pronator

Supinator C5, C6 Pronator teres C6, C7

Biceps brachii C5, C6 Pronator quadratus C7, C8, T1

Contracture: Pronation

Wrist Flexor Wrist Extensor

FC Radialis C6, C7, C8 EC Radialis C6, C7

FC Ulnaris C7, C8, T1 EC Ulnaris C7, C8

Palmaris longus C7, C8, T1 Finger extensor C7, C8

Finger flexor C7, C8, T1

Contracture: Flexion

Range of Motion Exercise

Gentle ROM exercise

2-3 daily x 10 repetitions

Torticollis

Concurrent phrenic nerve palsy

Poorer recovery from NBPP

Not severity of brachial plexus palsy (Narakas grade)

Strengthen Recovering Muscles

Shoulder girdle

Encourage Bi-Manual Activities

Reaching / Grasping

Encourage using muscle

Slowly increase the range

AVOID frustration

• Buoyancy (แรงลอยตว)

• Hydraulic resistance

• Push harder

• More resistance

• Hydrostatic pressure

• Blood circulation

• Relax 11 Aug 2017 Pariya Wimonwattrawatee, MD.

Sensory Deficit

Tactile stimulation

Various textured material

Vibration

Massage

Electrodiagnosis

Pre-operative workup

Biceps needle EMG at 1 month

Indication for referral

Malesssy MJ, et al. PloS One. 2011

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