Author(s): Marisa Osorio, DO, Nitin Bajaj, DO
Originally published: November 10, 2011 Last updated: October 31, 2024
Jump to:

Disease/Disorder

See Neonatal Brachial Plexus Injury Part 1

Essentials of Assessment

See Neonatal Brachial Plexus Injury Part 1

Rehabilitation Management and Treatments

Available or current treatment guidelines

There are presently no accepted standardized treatment guidelines for neonatal brachial plexus injury (NBPI). However, multidisciplinary treatment is standard of care; it optimizes functional recovery and minimizes unnecessary invasive interventions.1-3 Collaboration between families and health care professionals is ideal. Two main treatment approaches exist: conservative management and surgical management.1 

At different disease stages

Acute phase

Ideally, conservative treatment begins immediately. Family involvement is crucial to effective intervention. The goals of initial management are to maintain normal passive range of motion (ROM), thereby preventing contractures, and promoting functional use of the affected limb. If normal function and strength have not returned by one month of age or the newborn has Horner’s syndrome or flail limb at birth, the family should be referred to a specialty clinic for evaluation and management.4 The specialty clinic should ideally include pediatric physiatry, physical therapy, occupational therapy, and a surgical specialty team (e.g. plastic surgery, neurosurgery, orthopedic surgery). Through serial evaluations, the multidisciplinary team will evaluate the need for different conservative and surgical management options, which are reviewed below.

Passive ROM exercises for the affected limb (shoulder, elbow, forearm, wrist, and fingers) should be performed multiple times a day as tolerated.1,5 Selective strengthening of affected muscles and increasing awareness of the limb through sensory stimulation and mimicry of the unaffected limb are important in neural development.2,6 One study has shown cortical volume loss and changes in the primary and supplementary motor areas that are likely the result of decreased motor and sensory input from the affected extremity.7 Therefore, special attention should be paid to the affected side with guided exercises both with a therapist and at home with family and use of compensatory techniques can be taught to help with acquisition of developmental milestones.2,3,6   

Electrical stimulation to affected muscles may help improve muscle outcome after nerve regeneration occurs, though its efficacy is unclear.1,8

Modified constraint induced movement therapy (CIMT) combined with bimanual training has been shown to improve mobility, functional capacity, speed, range of motion, and hand manipulation ability.1,3,9

As plexus injuries selectively weaken muscle groups, muscle imbalance can lead to restricted motion, co-contraction of agonist/ antagonist muscles, and structural joint deformity.10 As such, botulinum toxin injections (in conjunction with therapies, casting, and surgery) may be used off label in NBPI to temporarily weaken healthy antagonistic muscles, alleviating muscle imbalances, co-contractions, and muscle contractures. This can help limb movement patterns to potentiate nerve recovery and motor learning.1-3,10 Three major indications for botulinum toxin injections include internal rotation/adduction contracture of the shoulder, elbow flexion/ extension lag, and forearm pronation contracture.10

Chronic/stable

Regardless of whether or not surgical intervention is performed, general therapeutic goals remain the same with emphasis on contracture prevention and acquisition of developmentally appropriate gross and fine motor skills. Adolescents with persistent deficits may continue to experience muscle imbalance, contracture, limb asymmetries, and atrophy leading to impaired activities of daily living (ADLs).11 Variable treatment outcomes and morphological asymmetries associated with functional impairment may result in psychosocial difficulties in children and adolescents with NBPI, which may impact school and activity participation as well as peer socialization.11,12 Emphasis should be on accommodations for school, assistive devices for ADLs and adaptations for activity participation.4 

Coordination of care

A specialty clinic with multidisciplinary care will help to guide the spectrum of care needs that occur throughout the child’s life and is necessary given the complexity of NBPI and variable extent of injury, musculoskeletal sequelae, prognosis, and recovery pattern.2 

Emerging/unique interventions

Surgical interventions are recommended in 10-30% of infants with NBPI.4 However, there is no formal consensus regarding the indications and timing of nerve surgery in NBPI,1,4 and there is research to suggest that early nerve surgery (age < 6 months) has no better outcome than nerve surgery after 6 months of age.13 There is a general consensus that infants with pan plexus injury (Narakas type III and IV) who lack elbow flexion will undergo nerve surgery at 3 months.1,2,5,14 In general, decisions for nerve surgery are made between 3 and 9 months of age with nerve surgery performed before age 1.4,14 Despite a lack of consensus, the following points are apparent:1,14

  • Patients who undergo microsurgery at 6 months have better outcomes than those who spontaneously recovered elbow flexion at 5 months.
  • Surgery is often recommended for patients with less than antigravity elbow flexion at 6 months of age.
  • Patients with complete NBPI may undergo surgery at 3-4 months of age.

Typical priorities for surgeons include restoration of hand function, elbow flexion, shoulder external rotation and abduction.14

Primary surgery (microsurgery) to the brachial plexus is the preferred initial surgical intervention for NBPI.  Microsurgeries include neurolysis (cleaning scar and fibrotic tissue from nerve), nerve transfer, and nerve grafting. Traditionally, nerve grafting was preferred as it utilizes a donor nerve, typically sural nerve, or synthetic conduit to provide a proper recovery pathway.1,4,14 The repaired nerves must regenerate axons from the proximal graft site in the neck to the distal target muscle before the muscle becomes permanently atrophied due to denervation.5 In nerve transfer, the zone of injury is left intact and an expendable fascicle from a functioning nerve is used to innervate a denervated muscle close to the motor endplate. Nerve transfers may include extraplexal nerves such as the spinal accessory nerve and intercostal nerves. Terminal branches of the plexus such as the ulnar, median, and radial nerves may also be used for an intraplexus transfer.4,5,14 Nerve transfer has become a more favorable option as the outcomes are equivalent to nerve grafting, there is decreased time to innervate the target muscles, operative time is shorter and associated cost is reduced.14,15 Microsurgery, in general, has resulted in improved postoperative shoulder function in 60-80% of cases and at least antigravity elbow flexion in 80% of cases.1,14

Secondary surgeries are for children who have functional motor deficits regardless of undergoing primary surgery. The goal of these surgeries is to maximize function while decreasing musculoskeletal deformities.4 The most common secondary surgery is tendon transfer for shoulder external rotation. This surgery reroutes select internal rotator tendons to the lateral part of the humerus to promote external rotation, giving children more ability to reach overhead for activities such as grooming and throwing.4 Other secondary surgeries are designed to address concerns such as wrist drop, limited thumb abduction, and rotational deformities at the forearm and humerus.4,14 

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Pediatric Rehabilitation Medicine (PRM) physicians are well trained to be the front line in assessment and diagnosis of NBPI.  Given the extensive knowledge of the neurologic and musculoskeletal systems, PRM physicians can determine if the presenting symptoms are related to a central nervous system lesion, fracture, brachial plexus injury or a combination of these. They can also implement intervention strategies to address common comorbidities such as torticollis and contractures.16 With higher rates of birth hypoxia and asphyxia than the general population, these children should also be screened for developmental and language delays.4,16,17 

Cutting Edge/Emerging and Unique Concepts and Practice

In treating children with NBPI, it is critical to consider patient expectations, pain and quality of life (QOL). One study found pain occurred in 66% of the study population with 70% of those reporting at least weekly symptoms.18 Parents also tend to report more pain and lower QOL for their child compared to peers.19 However, children who completed QOL measures had similar scores on domains of pain, peer relationships and mobility compared to their peers.20 This is in contrast to a survey of adults with NBPI that reported their brachial plexus palsy had a negative impact on hand function, activity participation, life function, pain and QOL.21 Further research is needed to validate measures specific to NBPI in order to better understand the impact of the injury and areas to target intervention. 

Gaps in the Evidence-Based Knowledge

Debate surrounding the indications and timing of NBPI surgical intervention persists. As such, advances in neuroimaging are sought after to help identify injury patterns and guide prognosis. Pilot study of a rapid, non-sedated, non-contrast, volumetric cube proton density MRI has shown that it can differentiate pre and postganglionic injury and correlates with functional performance at 6 months of age.22 More extensive research is needed to determine the validity of this biomarker.

Despite the unanimous consensus that treatment of NBPI begin with conservative management, certain rehabilitation techniques are lacking in evidence such as bracing, positional techniques, and taping to reduce glenohumeral dysplasia and shoulder and elbow contractures, weight shifts using the affected limb, and aqua therapy.3

Inclusion of NBPI specific content in assessing health related quality of life via patient reported outcomes is necessary to better capture specific challenges endured by this patient population.12

References

  1. Nelson MR. Birth brachial plexus palsy. In: Murphy KP, McMahon MA, Houtrow AJ, eds. Pediatric Rehabilitation: Principles and Practice. New York, NY: Springer Publishing Company; 2020. doi:10.1891/9780826147073.0024
  2. Schmieg S, Nguyen JC, Pehnke M, Yum SW, Shah AS. Team approach: management of brachial plexus birth injury. JBJS Reviews. 2020;8(7):e1900200. doi:10.2106/JBJS.RVW.19.00200
  3. Frade F, Gómez-Salgado J, Jacobsohn L, Florindo-Silva F. Rehabilitation of neonatal brachial plexus palsy: integrative literature review. J Clin Med. 2019;8(7). doi:10.3390/jcm8070980
  4. Osorio M, Lewis S, Tse RW. Promoting recovery following brith brachial plexus palsy. Pediatr Clin North Am. 2023;70(3):517-529. doi: 10.1016/j.pcl.2023.01.016
  5. Vuillermin C, Bauer AS. Boston Children’s Hospital approach to brachial plexus birth palsy. J Pediatr Orthop B. 2016;25(4):296-304. doi:10.1097/BPB.0000000000000330
  6. Smith B, Daunter A, Yang L, et al. An update on the management of neonatal brachial plexus palsy—replacing old paradigms. JAMA Pediatr 2018;172(6):585-591. doi:10.1001/jamapediatrics.2018.0124
  7. Longo E, Nishiyori R, Cruz T, Alter K, Damiano D. Obstetric brachial plexus palsy: can unilateral birht onset peripheral injury significantly affect brain development? Dev Neurorehab 2020;23(6):375-382. Doi:10.1080/17518423.2019.1689437
  8. Justice, D., Awori, J., Carlson, S., Chang, K. W., & Yang, L. J. (2018). Use of Neuromuscular Electrical Stimulation in the Treatment of Neonatal Brachial Plexus Palsy: A Literature Review. The Open Journal of Occupational Therapy, 6(3). https://doi.org/10.15453/2168-6408.1431
  9. Zielinski, I. M., van Delft, R., Voorman, J. M., Geurts, A. C. H., Steenbergen, B., & Aarts, P. B. M. (2019). The effects of modified constraint-induced movement therapy combined with intensive bimanual training in children with brachial plexus birth injury: a retrospective data base study. Disability and Rehabilitation, 43(16), 2275–2284. https://doi.org/10.1080/09638288.2019.1697381
  10. Buchanan PJ, Grossman JAI, Price AE, Reddy C, Chopan M, Chim H. The use of botulinum toxin injection for brachial plexus birth injuries: A systematic review of the literature. Hand (N Y). 2019;14(2):150-154. doi:10.1177/1558944718760038
  11. Bergman D, Rasmussen L, Chang KW-C, Yang LJ-S, Nelson VS. Assessment of Self-Determination in Adolescents with Neonatal Brachial Plexus Palsy. PM R. 2018;10(1):64-71. doi:10.1016/j.pmrj.2017.06.013
  12. Chang KW-C, Austin A, Yeaman J, et al. Health-Related Quality of Life Components in Children With Neonatal Brachial Plexus Palsy: A Qualitative Study. PM R. 2017;9(4):383-391. doi:10.1016/j.pmrj.2016.08.002
  13. Bauer AS, Kalish LA, Adamczyk MJ, Bae DS, Cornwall R, James MA, Lightdale-Miric N, Peljovich AE, Waters PM; Treatment and Outcomes of Brachial Plexus Injury (TOBI) Study Group. Microsurgery for brachial plexus injury before versus after 6 months of age: results of the multicenter treatment and outcomes of brachial plexus injury (TOBI) study. J Bone Joint Surg Am. 2020;102(3):194-204. doi: 10.2106/JBJS.18.01312
  14. Pulos N, Shaughnessy WJ, Spinner RJ, Shin AY. Brachial plexus birth injuries: A critical analysis review. JBJS Reviews. 2021;9(6). doi:10.2106/JBJS.RVW.20.00004
  15. O’Grady KM, Power HA, Olson JL, Morhart MJ, Harrop AR, Watt MJ, Chan KM. Comparing the efficacy of triple nerve transfers with nerve graft reconstruction in upper trunk obstetric brachial plexus injury. Plast Reconstr Surg. 2017 Oct;140(4):747-756. doi: 10.1097/PRS.0000000000003668
  16. Lewis S, Sweeney J. Comorbidities in infants and children with neonatal brachial plexus palsy: a scoping review wto inform multisystem screening. Phys Occup Ther Pediatr. 2023;43(5):503-527. doi: 10.1080/01942638.2023.2169091
  17. Chang K, Yang L, Driver L, et al. High prevalence of early language delay exists among toddlers with neonatal brachial plexus palsy. Pediatr Neurol 2014;51:384-9. doi: 10.1016/j.pediatrneurol.2014.04.021
  18. Ho E, Curtis C, Clarke H.  Pain in children following microsurgical reconstruction for obstetrical brachial plexus palsy.  J Hand Surg Am 2015;40(6):1177-83.
  19. Medeiros DL, Agostinho NB, Mochizuki L, Oliveira AS. Quality of lide and upper limb function of children with neonatal brachial plexus palsy. Rev Paul Pediatr. 2020 Mar 9;38:e2018304. doi: 10.1590/1984-0462/2020/38/2018304.
  20. Manske MC, Abarca NE, Letzelter JP, James MA. Patient-reported Outcomes Measurement Information System (PROMIS) Scores for Children With Brachial Plexus Birth Injury. J Pediatr Orthop. 2021 Mar 1;41(3):171-176. doi: 10.1097/BPO.0000000000001754.
  21. Dorich JM, Whiting J, Plano Clark VL, Ittenbach RF, Cornwall R. Impact of brachial plexus birth injury on health-related quality of life in adulthood: a mixed methods survey study. Disabil Rehabil. 2024 May;46(10):2042-2055. doi: 10.1080/09638288.2023.2212917
  22. Shen PY, Nidecker AE, Neufeld EA, Lee PS, James MA, Bauer AS. Non-sedated rapid volumetric proton denisty MRI predicts neonatal brachial plexus birth palsy functional outcome. J Neuroimaging. 2017;27(2):248-254. Doi:10.1111/jon.12389

Original Version of the Topic

Robert Rinaldi, MD. Neonatal Brachial Plexus Injury. 11/10/2011

Previous Revision(s) of the Topic

Charles Taylor, II, MD, Sheena Pillai, BS, Robert Rinaldi, MD. Neonatal Brachial Plexus Injury. 7/5/2018

Deborah Cassidy, DO, Amy Tenaglia, MD, Hana Azizi, MD. Neonatal Brachial Plexus Injury. 1/13/2022

Author Disclosure

Marisa Osorio, DO
Nothing to Disclose

Nitin Bajaj, DO
Nothing to Disclose