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

7-97%

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

Elbow

Wrist

Hand

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

Elbow

Wrist

Hand

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

30%

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

20%

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



Elbow

Contracture: Extension

Flexion Extension


Biceps brachii C5, C6 Triceps C6, C7, C8

Brachialis C5, C6 Anconeus C7, C8

Brachioradialis C5, C6


Elbow

Supinator Pronator


Supinator C5, C6 Pronator teres C6, C7

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

Contracture: Pronation


Wrist

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


Health & Medicine

Rehabilitation in Neonatal Brachial Plexus Palsy