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ADVANCE Perspective: Physical Therapy & Rehab Medicine

Infant Brachial Plexopathy Treatment is not 'Cookie Cutter'

Published January 23, 2013 8:16 PM by Brian Ferrie

The following post was written by ADVANCE guest blogger Brian Knutsen, OTR/L, CHT, president of Buzzards Bay Hand Therapy LLC, located in Marion and Lexington, MA.

SAN DIEGO -- One of Tuesday's hand rehab sessions, "Infant Brachial Plexopathy: Nonsurgical and Surgical Management," presented by Susan V. Duff, PT, OTR/L, EdD, CHT, Gregory G Heuer, MD, PhD, and Jamie Berggren, OTR/L, discussed the mechanism and etiology of a brachial plexus injury.

Brachial plexopathy is a unilateral traction injury of the brachial plexus caused by forced lateral flexion of the neck (separation of the head from the shoulder) either during gestation or delivery. The most frequent cause is shoulder dystocia either when the anterior shoulder is trapped behind the symphysis pubis or when the posterior shoulder is caught on sacral promontory of the mother.

The return of bicep function is the most important factor when determining prognosis and ultimate need for surgery vs. non-surgical treatment. The timeline when bicep function returns seems to guide the surgeon's decision making process as to when /if surgery is indicated. If bicep function is restored by two to three months, then conservative therapy has an excellent-to-good chance of being effective.

There are formal tests to evaluate bicep function; however one test I found interesting is the "cookie test." This test simply involves having a child attempt to bring a cookie to his mouth while observing for compensation. Dr. Heuer explained that this simple test is most helpful in determining the indications for surgery. He described protocols and treatment options following surgery and placed special significance on the importance of physician/therapist communication to ensure the best possible functional outcome.

The presentation featured videos depicting children with various degrees of brachial plexus pathology. It was interesting to see the movement patterns each child demonstrated and how they related to the severity of brachial plexus injury as well as the decisions to elect for surgical options.

Some of the video clips included the child's parent assisting with positioning during attempts to elicit certain movement patterns. I was pleased to see the clinician incorporating the parent in the therapeutic treatment of the child because these patients need care beyond the clinic. Parent involvement and proper positioning instruction for both active and passive movement is critical to ensure the best possible chance for success.

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