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14/07/2015
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Welcome to Allied Health
Telehealth
To receive an attendance certificate please complete your online evaluation at:
https://www.surveymonkey.com/r/brachialplexusmanagement
Neonatal brachial plexus palsy
Neonatal brachial plexus palsy
Toddlers and Pre Schoolers Allied Health Telehealth Session
Presented by: Fiona Sampson OT & Alison Chivers PT
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Indicators of Brachial Plexus Palsy
• Birth history often involving trauma
• Lack of movement in affected upper limb
• Lack of response to stimulation of affected arm
• Atypical posturing- ie waiter’s tip posture (internal rotation, pronation and wrist flexion)
Waiters tip
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http://emedicine.medscape.com/article/317057-overview
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Neonatal Brachial Plexus Palsy Protocol of Surgical Intervention
• 4-5 months : Severe injuries require nerve graft surgery.
• 9 months : Botox and casting considered for tightness into shoulder external rotation.
• 12 months : If shoulder external rotation movement is absent consider further botox and/or transfer of 1 nerve for external rotation.
• 18-24 months consider shoulder rebalancing (tendon transfer) if external rotation still limited.
When to refer to a specialist centre?
• Mild lesion cannot be distinguished reliably from severe lesions in the perinatal period.
• Only time reveals whether or not spontaneous recovery will occur.
• Absence of active flexion at one month of age is a good indicator for referral to a specialist centre.
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TODDLERS
Toddlers • Frequency of intervention
• Management of body function and structure
• Management of activity
and participation
• Surgical considerations
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Body Function and Structure
Maintenance of passive ROM • External rotation: most important • Adequate external rotation required
for movement above 90o
• Elbow extension
• Pronation / supination
Why do specific ROM losses occur?
• Growth
• Issues with denervated muscle
• Muscle imbalance
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Passive ROM: External Rotation
Difference between shoulder abducted and adducted
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Shoulder External Rotation Stretch
Pect Major, Ant Deltoid, Subscapularis, Teres Major, Latissimus Dorsi
Facilitating active movements
• Shoulder external rotation
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Facilitating active movements • Reaching into:
• shoulder abduction
• shoulder flexion
• Elbow extension
Facilitating active movements
• Supination and Pronation
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Specific strengthening
• Limits if muscle not adequately innervated
• Limits of cognitive understanding and cooperation
• E.g. Scapula winging/control
Strengthening • Developmentally
appropriate
• Positioning to eliminate gravity initially
• Progression to against gravity
• Functional goals
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Focus on affected upper limb development and function
• Prehension with affected hand
• Bimanual play development
PREHENSION: affected hand
• Initiation of reach
• Grasp and release
• Hands to midline
• Hand to mouth
• Prehension
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Prehension with affected hand
Digital grasp Pincer grasp
Bimanual upper limb development Issues:
• Focus on awareness of affected arm • Static stabilisation against body
• Static holding in affected hand
• Use of affected hand as assist (helper hand)
• Motor planning
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Developmental disregard and learned non use
Affected non dominant hand vs affected dominant hand
Reduced awareness of affected upper limb
Interventions Modified Constraint Induced Movement Therapy (Mod CIMT)
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Bimanual Therapy
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DOMINANCE • Affected dominant hand
Underlying weakness but easier to
facilitate use
• Affected non dominant hand
? Changing dominance
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Activities and Participation
• Child care
• Dressing
• Eating
• Pre-writing
• Play
• Climbing
• Early Ball skills
Pre Schoolers
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Management of body function and structure
• Maintenance of Passive ROM Shoulder external rotation
Elbow extension
Pronation / supination
• Facilitating active movements
Maintaining Passive ROM • Maintaining and facilitating
Shoulder external rotation
Elbow extension
Forearm pronation
• Child actively involved
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• Shoulder movements
• Abduction/ flexion
• External
• and internal rotation
Active movements
• Supination and pronation:
Gravity eliminated
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Supination Against gravity
Pronation: active
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Pre-Schoolers Activity and participation
• Table top fine motor function
– Prewriting development
– Stabilising paper
– Pencil grip
– Cutting
• Issues with hand dominance
• Shoulder internally
rotated
• Forearm across body
• Elbow off the table
• Forearm in mid position
Typical posture
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Ideal posture • Shoulder in mid position
• Hand at side of paper
• Forearm using full active pronation
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Bimanual skills
• Bimanual skill development
• Motor planning for bimanual tasks
Affected hand: dominant vs non dominant
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Cutting skills
Typical issues:
Wrist posture
Pronation or mid position of affected hand
Motor planning
Pre-Schoolers Activity and participation
• ADL issues and self help skills
(Developing independence)
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• Getting ready for school
–Ball skills
–Playground issues
• Falls
• Climbing
• Protection of arm
Interventions: Modified Constraint Induced Movement Therapy
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