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 OpolskiejSTRESZCZENIE
Obraz zmian patologicznych w obrębie samej kończyny górnej w przebiegu okołoporodowego uszkodzenia splotu ramiennego (OUSR) zależy od lokalizacji i ilości uszkodzonych włókien ner-wowych. Im rozleglejsze uszkodzenie i im bliższe rdzenia kręgo-wego, tym zmiany zarówno kostne, jak mięśniowe są większe. U dzieci z OUSR w miarę rozwoju motorycznego, na skutek nie-równomiernego 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 niedo-władnej kończyny górnej oraz badanie postawy ciała wykonano u dwóch dziewczynek w wieku 9 i 13 lat, które objęte były pro-cesem fizjoterapii o różnym natężeniu. Do oceny funkcji niedo-władnej kończyny górnej wykorzystano pięciostopniową skalę Malleta, natomiast postawę ciała oceniono metodą fotogra-ficzną. U 13-letniej dziewczynki od urodzenia prowadzono sys-tematycznie zabiegi rehabilitacyjne, a także zalecane ćwiczenia w domu. Natomiast u 9-letniej dziewczynki intensywność ćwi-czeń 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 funkcjonal-ność chorej kończyny oraz na proces kształtowania się prawi-dłowej postawy ciała.
Słowa kluczowe: okołoporodowe uszkodzenie splotu
ramien-nego, postawa ciała, fizjoterapia, dzieci
ABSTRACT
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 under-went 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 recom-mended 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 chil-dren 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,
physi-otherapy, children
The term obstetric brachial plexus injury (OBPI) is defined as a clinical syndrome of the consequences of inju-ries within different parts of the brachial plexus, emerg-ing 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 alto-gether constitute 10% of all the OBPI cases, at most [7,8].
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 inappro-priate 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 muscu-loskeletal 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 comprehen-sive treatment and the involvement of parents in the pro-cess of physiotherapy.
The aim of this study it to assess the impact of com-prehensive 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 neuro-surgical 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 diag-nosed with brachial plexus injury: Duchenne-Erb´s palsy on the right side. Physiotherapy treatment started at the neona-tal unit, where the girl´s mother was instructed on how to position the child´s affected upper limb and how to per-form 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 exer-cises daily as recommended by a physiotherapist, improv-ing 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
Fig.1. Sylwetka 9 letniej dziewczynki Posture of the 9-year-old girl
Fig. 2. Sylwetka 13 letniej dziewczynki Posture of the 13-year-old girl
RESULTS
The children under study were born with birth weight over 4000mg and in the course of the prolonged labor. Both fac-urse of the prolonged labor. Both fac-tors contribute to a high risk of OBPI incidence. In both sub-jects, global changes accompanying OBPI were noted but the observed degree of changes is less visible in the 13-year-old 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 demon-strated the III stage of OBPI severity in all tested ranges of motion. Observations carried out during exercises indi-cated 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 syn-drome 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 exer-cises, the girl used the affected upper limb actively.
DISCUSSION
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, some-times 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
conducted by a team of doctors, nurses, physiotherapists and properly trained parents has a crucial impact on the subse-quent functionality of the affected upper limb and, conse-quently, 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 shap-ing the child’s posture. The lack of upper limb movement does not provide the developing motor cortex with infor-mation 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 develop-ment, 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 mus-cles, contractures of muscles and periarticular structures are escalated.
Activity in asymmetrical movement patterns, cover-ing all stages of child´s motor development, contributes to posture malformation. Even after a child´s birth a notice-able 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 men-tioned 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 second-ary 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 den-ervation of some muscle groups of shoulder blade and the takeover of their function by other muscle groups, also trig-gers 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 com-pensatory scoliosis in the lumbar spine is also noted. Addi-tionally, 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 stand-ing position and contribute to the development of lower limbs’ alignment disorders [18].
Early detection of disorders and application of treat-ment from the motreat-ment of birth, through appropriate posi-tioning and activation of the paretic limb in all movement patterns, enables to provide stimulus to the cortex, neces-sary for shaping bilateral coordination patterns and aware-ness of body symmetry [16,18].
Exercises which are performed on a regular basis stim-ulate 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 pic-ture 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 per-formed 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, encoun-ters 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, influ-ences significantly the functionality of the affected upper limb and body posture formation.
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