Role of rehabilitation medicine in neotatal brachial plexus palsy, including classification, prevent further injury, prevent complication (and cause of complication), strengthen recovering muscles, achieve developmental milestone and electrodiagnosis

1. 11 Aug 2017 Pariya Wimonwattrawatee, MD.
การฟื้นฟูสมรรถภาพผู้ป่วย
Neonatal Brachial Plexus Palsy
(Rehabilitation in NBPP)

2. 11 Aug 2017 Pariya Wimonwattrawatee, MD.
Role of Rehabilitation
 Prevent further injury
 Prevent complication
 Strengthen recovering muscles
 Achieve developmental milestones
 Age appropriate functional use
 Electrodiagnosis

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Prevent Further Injury
 Mechanism: traction injury
 Incomplete injury
 Mobilization – painful
 Immolization shoulder 7-15 days
 Elbow to the body

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 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

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 Long-term limb immobilization
 Associated with shoulder deformity
 Except fractures

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Prevent Further Injury
 Clavicle fracture
 Humerus fracture
 Bilateral NBPP
 Associated fracture

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Prevent complication
 Muscle atrophy
 Limited range of motion / contracture
 Shoulder
 Elbow
 Wrist
 Hand
 Shoulder deformity
 Glenoid retroversion
 Posterior subluxation

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Prevent Complication
 Radial head subluxation
 Compensatory movement
 Injury to extremity (lack of sensation)
 Torticollis

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Prevent complication
 Muscle atrophy
 Limited range of motion / contracture
 Shoulder
 Elbow
 Wrist
 Hand
 Shoulder deformity
 Glenoid retroversion
 Posterior subluxation

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Electrical Stimulation
 Retard muscle atrophy
 Preserve endplate

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Limited ROM / Contracture

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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%

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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

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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

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Pectoralis major / minor (C5-T1 roots)

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Internal Rotation
Contracture
 Most frequent
 Appear early and rapid
 5 months
 Responsible for growth problems of the
glenohumeral joint

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Shoulder
Adductor Abductor
Muscle Root Muscle Root
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

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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

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Elbow
Contracture: Extension
Flexion Extension
Muscle Root Muscle Root
Biceps brachii C5, C6 Triceps C6, C7, C8
Brachialis C5, C6 Anconeus C7, C8
Brachioradialis C5, C6

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Elbow
Supinator Pronator
Muscle Root Muscle Root
Supinator C5, C6 Pronator teres C6, C7
Biceps brachii C5, C6 Pronator quadratus C7, C8, T1
Contracture: Pronation

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Wrist
Wrist Flexor Wrist Extensor
Muscle Root Muscle Root
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

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Range of Motion Exercise
 Gentle ROM exercise
 2-3 daily x 10 repetitions

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Torticollis
 Concurrent phrenic nerve palsy
 Poorer recovery from NBPP
 Not severity of brachial plexus palsy
(Narakas grade)

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Strengthen Recovering
Muscles
 Shoulder girdle

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Encourage Bi-Manual
Activities

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Reaching / Grasping
 Encourage using
muscle
 Slowly increase the
range
 AVOID frustration

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35. • Buoyancy (แรงลอยตัว)
• Hydraulic resistance
• Push harder
• More resistance
• Hydrostatic pressure
• Blood circulation
• Relax
11 Aug 2017 Pariya Wimonwattrawatee, MD.

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Sensory Deficit
 Tactile stimulation
 Various textured material
 Vibration
 Massage

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Electrodiagnosis
 Pre-operative workup
 Biceps needle EMG at 1 month
 Indication for referral
 Malesssy MJ, et al. PloS One. 2011

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