The importance of physiotherapy in the process of

PRACA ORYGINALNA/ORIGINAL ARTICLE
The importance of physiotherapy in the process of posture formation
in children with obstetric brachial plexus injury
Znaczenie fizjoterapii w procesie kształtowania się postawy ciała u dzieci
z okołoporodowym uszkodzeniem splotu ramiennego
Karina Słonka, Anna Sobolska, Lidia Hyla Klekot, Małgorzata Proszkowiec
Wydział Wychowania Fizycznego i Fizjoterapii Politechniki Opolskiej
STRESZCZENIE
ABSTRACT
The term obstetric brachial plexus injury (OBPI) is
defined as a clinical syndrome of the consequences of injuries within different parts of the brachial plexus, emerging in the course of a prolonged labor. The damages may
include nerve bundles, trunks and roots of spinal nerves
and they determine the clinical severity from neuropraxia
to avulsion [1–3]. The reported incidence of OBPI is 0.5 to
3 per 1000 live births [4]. In most children brachial plexus
paralysis resolves without surgical treatment (70 – 90%),
the rest of children experience a partial return of motor
function or no improvement is achieved [4,5]. Gilbert and
Tassin [6] indicate that all patients who make satisfactory
recoveries have detectable deltoid and biceps contractions
by the third month of age.
The most common type of brachial plexus injury (73 –
86% of cases) is the upper palsy, so called Duchenne-Erb’s
palsy, in which C5 and C6 spinal nerve roots are damaged.
The lower palsy – Klumpke’s palsy involving C7, C8 and T1
roots is rarely reported, it applies to approximately 2–3% of
children with OBPI and the total plexus paralysis is observed
in 1% of the patients. The atypical and complete palsies altogether constitute 10% of all the OBPI cases, at most [7,8].
Obraz zmian patologicznych w obrębie samej kończyny górnej
w przebiegu okołoporodowego uszkodzenia splotu ramiennego
(OUSR) zależy od lokalizacji i ilości uszkodzonych włókien nerwowych. Im rozleglejsze uszkodzenie i im bliższe rdzenia kręgowego, tym zmiany zarówno kostne, jak mięśniowe są większe.
U dzieci z OUSR w miarę rozwoju motorycznego, na skutek nierównomiernego obciążania ciała, dochodzi do powstania wad
postawy ciała, w szczególności asymetrii tułowia, miednicy i
wad kończyn dolnych. Celem pracy jest omówienie wpływu
kompleksowej fizjoterapii na kształtowanie się postawy ciała u
dwojga dzieci po przebytym OUSR, u których przeprowadzono
wczesną interwencję neurochirurgiczną. Ocenę funkcji niedowładnej kończyny górnej oraz badanie postawy ciała wykonano
u dwóch dziewczynek w wieku 9 i 13 lat, które objęte były procesem fizjoterapii o różnym natężeniu. Do oceny funkcji niedowładnej kończyny górnej wykorzystano pięciostopniową skalę
Malleta, natomiast postawę ciała oceniono metodą fotograficzną. U 13-letniej dziewczynki od urodzenia prowadzono systematycznie zabiegi rehabilitacyjne, a także zalecane ćwiczenia
w domu. Natomiast u 9-letniej dziewczynki intensywność ćwiczeń terapeutycznych była mniejsza, dodatkowe ćwiczenia nie
były wykonywane. Na podstawie przeprowadzonych badań
stwierdzono, że konsekwentna i systematyczna fizjoterapia
dzieci po przebytym OUSR ma korzystny wpływ na funkcjonalność chorej kończyny oraz na proces kształtowania się prawidłowej postawy ciała.
Słowa kluczowe: okołoporodowe uszkodzenie splotu ramiennego, postawa ciała, fizjoterapia, dzieci
Vol . 20/2011, nr 40
Pathological changes within the upper limb in the course of
obstetric brachial plexus injury (OBPI) depend on the location
and number of impaired nerve fibers. The more extensive and
closer to the spinal cord the damage, the more substantial the
changes both in bones and muscles. As the motor development
proceeds, children with OBPI develop posture malformations
due to uneven body loading, in particular the asymmetry of the
trunk and pelvis and the lower extremity deformities. This study
aims to discuss the comprehensive physiotherapy impact on
the formation of posture in two children with OBPI who underwent an early neurosurgical intervention. The evaluation of the
affected upper limb function and body posture assessment were
conducted in two girls (age 9 and 13), who were subjected to
the physiotherapy process of varied intensity. To assess the
function of the affected upper limb we used Mallet´s five-stage
scale, while the body posture was evaluated with the use of a
photographic method. The 13-year-old girl was provided with
regular physical rehabilitation since her birth, including recommended exercises which were performed at home. In contrast,
the 9-year-old girl was given physiotherapy treatment of lower
intensity and additional exercises were not included. The test
results show that consistent and regular physiotherapy of children with OBPI have a beneficial influence on the functionality
of the affected upper limb and on the process of the correct
body posture formation.
Key words: obstetric brachial plexus injury, posture, physiotherapy, children
35
K. Słonka, A. Sobolska, L. Hyla Klekot et al.
PRACA ORYGINALNA/ORIGINAL ARTICLE
It is widely recognized that the etiology of OBPI is
associated with a perinatal trauma [8,9]. The trauma is
caused by the forces generated in an attempt to extract the
fetus. Injury to the plexus may also result from an inappropriate positioning of the fetus in the uterus [10].
In the case of permanent injury to the nerve fibers local
changes occur such as: flaccid paralysis of the upper limb,
hypoplasia of the shoulder and arm, and in the long term,
shoulder dysplasia with the humeral head dislocation,
atrophy of the affected muscles, muscle contractions and
chronic pain [11].
Apart from the local disorders related to the musculoskeletal structures of the paretic or flaccid upper limb,
global effects of brachial plexus injury evolve. Using only
one upper limb by a child in movement patterns for a long
time leads to the lack of the appropriate functional patterns
activation to stabilize the trunk. Activity in asymmetrical
motor patterns contributes to posture malformations [12].
The clinical picture of global changes in children with
OBPI depends on: ● the severity of brachial plexus injury
(including the pace of recovery from paralysis) ● the time
of a child´s diagnosis ● the commencement of comprehensive treatment and the involvement of parents in the process of physiotherapy.
The aim of this study it to assess the impact of comprehensive physical therapy on the posture formation in
two girls with OBPI who underwent an early neurosurgical
treatment.
MATERIAL AND METHODS
This case study covered two people participating in a 3-week
physical rehabilitation stay at the Rehabilitation Centre for
Children and Youth in Suchy Bór. The girls were subjected
to the physiotherapy treatment because of their posture
abnormalities. The photographs registering body silhouettes
were taken to measure the posture and to assess the function
of the affected upper limb, the 5-stage Mallet classification,
presented in table I, was applied. The table includes the II,
III and IV stages of severity of OBPI. However, the I and V
stage have not been described in the table, as in the I stage
there is a complete lack of movement and in the V stage
there is a full range of performed motion.
Case 1
The 9-year-old girl was born in the natural way from the
first pregnancy, with birth weight of 4300g and body length
of 54 cm. The childbirth was prolonged. During the first
minute of her life the infant girl was awarded 3 points on
the Apgar scale and in the third minute – 7 points. She was
diagnosed with brachial plexus injury: Duchenne-Erb´s
palsy on the right side. Starting from the age of 5 weeks
the girl received physiotherapy treatment according to V.
Vojta two times per week. At the age of 6 months a neurosurgical procedure involving the release of nerve adhesions
was performed. From the age of 2 onwards NDT Bobath
therapy was applied once a week. From the age of 6 – the
girl exercised to improve her upper limb function, was given
hydrotherapy and physical therapy modalities once a week.
At home the girl’s parents exercised with her irregularly,
explaining it with the child´s reluctance to physical effort.
Case 2
The 13-year-old girl was born in the natural way from the
first pregnancy, with birth weight of 5100g and body length
of 56 cm. The childbirth was prolonged. During the first
minute of her life the infant girl was awarded 6 points on the
Apgar scale and in the third minute – 9 points. She was diagnosed with brachial plexus injury: Duchenne-Erb´s palsy on
the right side. Physiotherapy treatment started at the neonatal unit, where the girl´s mother was instructed on how to
position the child´s affected upper limb and how to perform the massage and exercises. In the first three years of
life physical exercises of Vojta’s method and then of NDT
Bobath were applied daily. At 3 months of age the nerve
decompression surgery was carried out.
The girl, with her mother’s assistance, performed exercises daily as recommended by a physiotherapist, improving her upper limb function. In addition, from the age of
6 onwards, the child regularly i.e. twice a week, attended
a swimming pool, was actively involved in a variety of
sports including jogging, skating, skiing and gymnastics.
Tab. I. Mallets´s classification in the assessment of the injured plexus function [13] Klasyfikacja Malleta w ocenie funkcji
uszkodzonego splotu ramiennego [13]
Movement in the Mallets´s
classification
II stage
III stage
IV stage
Active abduction
below 30°
30° – 90°
over 90°
External rotation
0°
below 20°
over 20°
Hand to head
impossible
difficult
easy
Hand to back
impossible
S1
T12
Hand to mouth
lack of horizontal adduction
50% of horizontal adduction
100% of horizontal adduction
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N eu rol ogi a D zie cię ca
The importance of physiotherapy in the process of posture formation in children with obstetric brachial plexus injury
RESULTS
Fig.1. Sylwetka 9 letniej dziewczynki Posture of the 9-year-old
girl
The children under study were born with birth weight over
4000mg and in the co��������������������������������������
urse of the prolonged labor. Both factors contribute to a high risk of OBPI incidence. In both subjects, global changes accompanying OBPI were noted but
the observed degree of changes is less visible in the 13-yearold girl, who works every day together with her mother on
improving the affected limb function and is very active in
various sport disciplines (Table II).
The 9-year-old girl: Clinical evaluation of the affected
upper extremity function using the Mallet scale demonstrated the III stage of OBPI severity in all tested ranges
of motion. Observations carried out during exercises indicated that the child was reluctant to use the affected upper
limb, she often helped herself with a healthy hand and had
a visible dysfunction of the grasping ability within the
affected hand. The girl was diagnosed with a neglect syndrome of the affected upper limb in daily life activities and
impaired motor coordination of the affected limb during
locomotion. The child tiptoed while walking.
The 13-year-old girl: Clinical evaluation of the affected
upper extremity function using the Mallet scale revealed
no significant mobility restriction in the following ranges
of motion: abduction, external rotation and hand to head –
IV stage of OBPI severity, hand to back and hand to mouth
– III stage of OBPI severity. During the performed exercises, the girl used the affected upper limb actively.
DISCUSSION
Fig. 2. Sylwetka 13 letniej dziewczynki Posture of the 13-yearold girl
Obstetric brachial plexus palsy is a serious damage to the
peripheral nervous system. It is therefore appropriate to plan
a special treatment for a young patient with OBPI, sometimes including neurosurgical intervention and early, regular
physiotherapy treatment. Such understanding of the therapy
Tab. II. Summary results of the body posture assessment of people subjected to examination Zestawienie wyników oceny
postawy ciała u badanych osób
Elements of frontal plane posture
assessment
9-year-old girl
13-year-old girl
Alignment of shoulder and scapula
Visible scapular depression on the right side
Slight asymmetry
Pelvic alignment
Visible asymmetry
Slight asymmetry
Knee alignment
Genu valgum
No change
Calcaneal alignment
Eversion
Eversion
Elements of sagittal plane posture
assessment
9-year-old girl
13-year-old girl
Alignment of shoulder and scapula
Excessive scapular protraction on the right side
Slight scapular protraction on the right side
Pelvic alignment
Increased anterior pelvic tilt
No change
Knee alignment
Flexed position of the knees
Back knees with thighs in internal rotation
X-ray analysis
9-year-old girl
13-year-old girl
Posteroanterior standing radiograph
S-shaped scoliosis:
- dextroconvex thoracic scoliosis, Cobb angle of 10
degrees
- sinistroconvex scoliosis - Cobb angle of 6 degrees
Slight dextroconvex thoracic scoliosis,
Cobb angle of 5 degrees
Vol . 20/2011, nr 40
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K. Słonka, A. Sobolska, L. Hyla Klekot et al.
PRACA ORYGINALNA/ORIGINAL ARTICLE
conducted by a team of doctors, nurses, physiotherapists and
properly trained parents has a crucial impact on the subsequent functionality of the affected upper limb and, consequently, on the everyday functioning of a child [14].
Nath et al. [15] and Matyja et al. [16] emphasize that
injury to the brachial plexus has a major influence on shaping the child’s posture. The lack of upper limb movement
does not provide the developing motor cortex with information about the affected upper limb and significantly
modifies the child’s body schema formation since the birth.
It results in various motor difficulties associated with a
delay of transition to subsequent phases of motor development, omitting the correct movement patterns, thus having
a decisive influence on the gross and fine motor skills of
the growing child. The absence of active movement of the
affected upper limb and the absence of impulses from the
central nervous system to the muscles lead gradually to
muscular atrophy and blood supply disorders in the muscles, contractures of muscles and periarticular structures
are escalated.
Activity in asymmetrical movement patterns, covering all stages of child´s motor development, contributes to
posture malformation. Even after a child´s birth a noticeable asymmetrical placing of the head and trunk can be
observed, mostly towards the affected upper limb. Injury
to the short nerves of brachial plexus is the most frequently
encountered form of OBPI (Duchenne-Erb’s palsy) and
leads to partial or complete denervation of muscles which
are important for the correct scapula alignment: rhomboid
muscles and serratus anterior muscle. The above mentioned muscles cooperate in a kinetic chain of scapula.
Additionally, serratus anterior muscle provides scapular
stability and ensures the base for the function of upper
extremity mobility. Denervated serratus anterior muscle
gives a picture of scapula alata [17] and leads to secondary dysfunction of the hand. Scapular stabilization function
may be taken over by pectoralis minor muscle, positioning
shoulder blade in protraction, which is disadvantageous
from the biomechanical point of view.
The imbalance in a trunk muscle tone, caused by denervation of some muscle groups of shoulder blade and the
takeover of their function by other muscle groups, also triggers changes in the alignment of the cervical and thoracic
spine, including scoliosis. The direction of scoliosis can be
either towards the paretic limb or opposite, depending on
the direction of a child’s torso inclination during various
activities such as sitting, standing and walking. The compensatory scoliosis in the lumbar spine is also noted. Additionally, motor loss of the upper extremity is compensated
by the movement of the facet joints during flexion and
abduction of the arm. As a result, there is an increased and
exaggerated lumbar lordosis. The changes in trunk muscle
tone, associated with a more frequent use of healthy upper
limb, influence uneven body weight distribution in a standing position and contribute to the development of lower
limbs’ alignment disorders [18].
Early detection of disorders and application of treatment from the moment of birth, through appropriate positioning and activation of the paretic limb in all movement
patterns, enables to provide stimulus to the cortex, necessary for shaping bilateral coordination patterns and awareness of body symmetry [16,18].
Exercises which are performed on a regular basis stimulate proprioceptors in the joints and are significant for the
regulation of muscle tone of the affected shoulder blade
and upper limb. In addition, they prevent the transfer of
movement to other muscles of scapular kinetic chain as
well as secondary changes in the alignment of cervical and
thoracic spine facets and pelvis.
CONCLUSION
The study conducted by the authors shows that the picture of local and global changes in both subjects with
Duchenne-Erb´s palsy is correlated with the intensity of
comprehensive treatment, in particular with its component
of exercises recommended by the physiotherapist and performed at home. In the girl, who trains regularly at home
and plays a variety of sports, the severity of local changes
and in body posture is insignificant. However, the girl who
exercises reluctantly and irregularly at home, encounters considerable severity of the changes discussed above.
To sum up, comprehensive physiotherapy received by the
children with OBPI from their first weeks of life; conducted
in hospital, ambulatory treatment unit, and at home, influences significantly the functionality of the affected upper
limb and body posture formation.
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Adres do korespondencji:
Katedra Podstaw Fizjoterapii, Wydział Wychowania Fizycznego i Fizjoterapii , ul. Prószkowska 76, Opole, e-mail [email protected]
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