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Home Exercise DVD Promotes Exercise Accuracy by Caregivers of Children and Adolescents With Brachial Plexus Palsy
Abstract
Objective:
To evaluate the accuracy of home exercise performance by caregivers of children with neonatal brachial plexus palsy (NBPP) who use digital versatile disc (DVD) guidance.
Design:
Prospective cohort study.
Setting:
Brachial Plexus Clinic at the University of Michigan.
Participants:
Seventy-six adult caregivers of a consecutive cohort of pediatric patients with NBPP.
Methods:
Caregivers received the Home Exercise Program for Brachial Plexus Palsy DVD and an initial demonstration of correct hand placement and movement patterns by 1 of 2 occupational therapists. At times A, B, and C (approximately 3, 6, and 12 months), caregiver accuracy in exercise performance at each joint and standard measurements of arm function were recorded.
Main outcome measurements:
Caregiver accuracy in correct hand placement and movement pattern during exercise performance was evaluated with use of a dichotomy scale (yes/no) at each joint. Active and passive range of motion were assessed as indicators of arm function.
Results:
The mean patient age was 38 months, and the median Narakas score was 2. No significant difference in exercise accuracy for all upper extremity joints between the initial evaluation and times A, B, and C or between individual times was observed, except at the shoulder (98.9% initially to 88.3% at time A; P = .0002) and elbow (100% initially to 96.6% at time A; P = .04). Regarding arm function, an increase in active range of motion for shoulder flexion, elbow flexion, forearm supination, wrist extension, and finger flexion was observed during the study period.
Conclusions:
Shoulder and elbow exercises may be more complex, requiring more frequent performance review with the caregiver. However, the home exercise DVD may benefit patients with NBPP and their caregivers and may provide an adjunct to formal therapy sessions.
... Subsequent research has focused on the use of video recordings for patient instruction. The authors found that using videotape was at least as effective as direct teaching, 9 if not more effective, 10,11 in instructing subjects to accurately perform exercises. ...
... These findings concur with previous studies demonstrating that CEV instruction was as effective as one-on-one provider-subject interaction in teaching PT exercises. 1,9,10,11 These results are also in agreement with previous work using various motor tasks (for example, throwing with subject's non-dominant hand) that have demonstrated the utility of corrective feedback in improving performance. 13 Importantly, the current results extend on previous work using a CEV 11 by demonstrating the efficacy of CEV using an independently created video and that information gained from the CEV can be retained by subjects up to one week later. ...
Background and purpose:
The accurate performance of physical therapy exercises can be difficult. In this evolving healthcare climate it is important to continually look for better methods to educate patients. The use of handouts, in-person demonstration, and video instruction are all potential avenues used to teach proper exercise form. The purpose of this study was to examine if a corrected error video (CEV) would be as effective as a single visit with a physical therapist (PT) to teach healthy subjects how to properly perform four different shoulder rehabilitation exercises.
Study design:
This was a prospective, single-blinded interventional trial.
Methods:
Fifty-eight subjects with no shoulder complaints were recruited from two institutions and randomized into one of two groups: the CEV group (30 subjects) was given a CEV comprised of four shoulder exercises, while the physical therapy group (28 subjects) had one session with a PT as well as a handout of how to complete the exercises. Each subject practiced the exercises for one week and was then videotaped performing them during a return visit. Videos were scored with the shoulder exam assessment tool (SEAT) created by the authors.
Results:
There was no difference between the groups on total SEAT score (13.66 ± 0.29 vs 13.46 ± 0.30 for CEV vs PT, p = 0.64, 95% CI [-0.06, 0.037]). Average scores for individual exercises also showed no significant difference.
Conclusion/clinical relevance:
These results demonstrate that the inexpensive and accessible CEV is as beneficial as direct instruction in teaching subjects to properly perform shoulder rehabilitation exercises.
Level of evidence:
1b.
... Exclusion criteria comprised home performance of nonefull-arc ROM exercises, late (>6 months) initiation of full ROM exercises, other diagnoses conferring difficulties in arm movement or musculoskeletal abnormalities, and inability to attend scheduled clinic or radiographic appointments. One of 2 occupational therapists demonstrated the full PROM exercises to the children, and each patient received a DVD entitled "Home Exercise Therapy Program for Brachial Plexus Palsy" [29,30] to support the prescribed regimen of home exercises (at least 4-5 times per day). Standard clinical measurements included active ROM (AROM), PROM, manual muscle testing using Medical Research Council (MRC) scoring [31], limb length/circumference, self-reported presence or absence of pain, Narakas classification [32], modified version of Birch classification of shoulder deformity scoring [33], and acquisition of developmental milestones. ...
... In addition, 48% of the children (22 of 46) participated in formal therapy programs, and 68% (15 of 22) reported a therapy frequency of at least once a week. Multimedia assistance has been associated with increased compliance and performance accuracy of at-home ROM exercises [29,30]. ...
Children with neonatal brachial plexus palsy (NBPP) are often prescribed shoulder range of motion (ROM) exercises; however, extent and timing of exercise implementation remains controversial in the context of shoulder joint integrity. The association of ROM exercises to delayed posterior shoulder subluxation (PSS) is unknown.
To determine prevalence of PSS in children with NBPP who began full passive ROM exercises before 6 months of age, and children characteristics associated with development or absence of PSS.
Cross-sectional study.
Tertiary care NBPP referral center.
Forty-six children with NBPP aged 24-57 months, who initiated full ROM exercises before 6 months of age.
One radiologist conducted bilateral shoulder ultrasound on each child to evaluate for PSS. One occupational therapist evaluated each child clinically for PSS using defined parameters without knowledge of ultrasound results.
By ultrasound, 20% of children had PSS; 46% had PSS by clinical examination. Shoulder active ROM limitations and history of shoulder surgery were associated with presence of PSS. Extent of NBPP was not associated with PSS.
Nine of 46 children (20%) met ultrasound criteria for PSS; alpha angle was 58±21 degrees (mean±SD). Twenty-one children (46%) met clinical criteria. Mean age at examination was 35±10 months. Shoulder active ROM (P≤.004) was associated with PSS, whereas passive ROM was not (P≥.08). History of secondary shoulder surgery and primary nerve graft repair were associated with PSS (P=.04). Extent of NBPP by Narakas classification was not associated with PSS (P=.48).
Early use of full-arc passive ROM home exercise program is not associated with increased prevalence of PSS in children with NBPP compared to prevalence of PSS in published literature. We suggest careful clinical examination, based on defined criteria, provides a reasonable screening examination for evaluating PSS that can be confirmed by non-invasive ultrasound.
Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
... The need for increased awareness of NBPP remains: while approximately three-fourths of our participants treat pediatric patients, the majority do not feel confident in NBPP diagnosis and management. Considering that the population of physicians without self-reported confidence in treating NBPP consists of the same physicians most likely to interact with patients suffering from NBPP, there is an urgent need for more NBPP education [33][34][35][36]. ...
PurposeEarly referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP.MethodsA 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge.ResultsOf the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner’s syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation.Conclusions
Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.
... In the setting of physiatry, an exercise regimen initiated early in the course of the disease has been shown to be effective in a spectrum of pathologies. [23][24][25] Although CF should be no different, the data that would support the hypothesis of the importance of early intervention in this population are still lacking. A pivotal study can include patient groups who can and cannot attend to these programs and, therefore, the change in postural deformities in the long-term can be documented. ...
Objectives: This study aims to investigate the effects of postural exercises as an adjunct to chest physiotherapy program on respiratory function, exercise tolerance, quality of life (QoL), and postural stability in patients with cystic fibrosis (CF).
Patients and methods: In this single-blind, randomized-controlled trial, 19 pediatric CF patients (11 males, 8 females; mean age: 9.36 years; range, 6 to 14 years) were randomly allocated to chest physiotherapy and postural exercise program (Group 1, n=10) or chest physiotherapy program alone (Group 2, n=9) between March 2017 and October 2017. Respiratory functions were assessed with pulmonary function tests, whereas exercise tolerance with the Modified Shuttle Test (MST), quality of life with the Cystic Fibrosis Questionnaire-Revised Child Version (CFQR), and postural stability with the Limits of Stability Test (LOS). All tests were performed before treatment and six weeks, three months, and six months after treatment.
Results: Respiratory functions were improved in both groups; however, these changes were not statistically significant. The MST increased after treatment in both groups (p<0.001 and p=0.003 respectively), without a significant difference between the groups. Emotional function and treatment difficulties subdomains in CFQR were significantly increased only in the group with postural exercises (p<0.05).
Conclusion: The postural exercise program in addition to chest physiotherapy in pediatric CF patients whose postural changes were not taken place did not cause significant changes in respiratory function, exercise tolerance, and postural stability; however, it affected the emotional state well and improved the compliance with the treatment.
... 9,13 However, shoulder exercises requiring scapular stabilization may be difficult for untrained caretakers to perform correctly. 31 Monitoring passive shoulder motion over time is important in children with BPBP because loss of passive external rotation is a sign of GH dysplasia and may indicate further assessment and intervention. 6,7,11e13,22e26,29 Given the importance of maintaining and measuring passive motion in children with BPBP, this study aimed to determine the most effective means of stretching the GH joint and the feasibility of at-home stretching. ...
Purpose:
To quantify the effects of scapular stabilization on scapulothoracic and glenohumeral (GH) stretching.
Methods:
Motion capture data during external rotation and abduction with and without scapular stabilization were collected and analyzed for 26 children with brachial plexus birth palsy. These positions were performed by an experienced occupational therapist and by the child's caretaker. Scapulothoracic and GH joint angular displacements were compared between stretches with no stabilization, stabilization performed by the therapist, and stabilization performed by the caretaker. The relationship between the age and ability of the therapist and caretaker to perform the stretches with scapular stabilization was also assessed.
Results:
During external rotation there were no significant differences in either the scapulothoracic or GH joint during stabilization by either the therapist or the caretaker. During abduction, both scapulothoracic and GH joint angular displacements were statistically different. Scapulothoracic upward rotation angular displacement significantly decreased with scapular stabilization by the therapist and caretaker. Glenohumeral elevation angular displacement significantly decreased with scapular stabilization performed by the therapist and caretaker. There were only weak correlations between age and the differences in scapulothoracic and GH joint angular displacement performed by both the therapist and the caretaker.
Conclusions:
The findings of this study indicate that scapular stabilization may be detrimental to passive stretching of the GH joint in children, as demonstrated by a reduced stretch. Based on the findings of this study, we have changed our practice to recommend passive stretches without scapular stabilization for children aged 5 years and older with brachial plexus birth palsy. In infants and children aged less than 5 years, we now recommend stretching with and without scapular stabilization until the effect of scapular stabilization is objectively assessed in these age groups.
Level of evidence/type of study:
Therapeutic IV.
... Exercise gives patients increased self-efficacy; less anxiety, stress, and depression; and better overall wellbeing. [17][18][19] Regular exercise has shown to have cognitive benefits in improving cognitive function, sleep, learning, and memory. 17,18 Athletes, who are conditioned to an active lifestyle, may be at risk of feeling isolated and removed during concussion recovery. ...
Clinical question:
Is aerobic exercise more beneficial in reducing symptoms than current standard care in patients with prolonged symptoms or PCS lasting longer than 4 weeks? Summary of Key Findings: After a thorough literature search, 4 studies were selected relevant to the clinical question. Of the 4 studies, 1 was a randomized control trial and 3 were case series. All 4 studies investigate aerobic exercise protocol as treatment for PCS.(1-4) Three articles demonstrated a greater rate of symptom improvement from baseline assessment to follow-up after a controlled sub-symptomatic aerobic exercise program.(2-4) One study showed a decrease in symptoms in the aerobic exercise group compared to the full body stretching group.(1) Clinical Bottom Line: There is moderate evidence to support sub-symptomatic aerobic exercise as a treatment of PCS, therefore it should be considered as a clinical option for reducing PCS and prolonged concussion symptoms. A previously validated protocol, such as the Buffalo Concussion Treadmill Test, Balke Protocol, or Rating of Perceived Exertion (RPE) as mentioned in this critically appraised topic should be used to measure baseline values and treatment progression. Strength of Recommendation: Level C evidence exists that aerobic exercise protocol is more effective than the current standard of care in treating PCS.
Brachial plexus birth palsy (BPBP) is a neurological injury in newborns during childbirth. There is a dysfunction of the upper limb nerves with a variable recovery rate. The severity varies depending on the number and location of damaged nerves. The diagnosis is based on medical history and a physical examination. Successful treatment begins with understanding the anatomy of the brachial plexus and the pathophysiology of nerve injury. BPBP classifications can guide the prognosis and the management as they are based on the extent and anatomy of nerve injury, as well as clinical presentation. Serial physical examinations and a thorough clinical history form the basis of the treatment plan that relies upon occupational/physical therapy but may include nerve reconstruction and secondary musculoskeletal surgeries. The affected infants have an overall optimistic prognosis, with the majority recovering adequate use of the affected arm. The rate of spontaneous recovery ranges between 75% and 90%. Of importance is an early referral to interdisciplinary clinics and acquiring awareness of the psychosocial and quality-of-life problems that surround cases of chronic disablement of BPBP.
Brachial plexus birth palsy (BPBP) is classified as a preganglionic or postganglionic injury based on the site of injury. Most patients recover spontaneously and are followed up with clinical evaluation; however, permanent sequelae are not uncommon. For patients with persistent neurologic deficits, clinical and radiologic evaluation is crucial. Untreated BPBP can progress to significant sequelae, such as muscle contractures and glenohumeral dysplasia (GHD). Timely characterization of these entities based on different imaging modalities is a high priority for optimal patient outcomes. We describe the anatomy and pathogenesis, as well as the different imaging modalities involved in the evaluation and classification of BPBP and GHD.
Introduction:
Neonatal brachial plexus palsy (NBPP) results in muscle weakness and impaired somatosensory function of the arm. Current functional assessment is primarily based on clinician-elicited measurements including muscle strength and range of motion. To what extent these measures are representative of real-world arm movement is unclear. However, advances in wearable technology have made it possible to monitor real-world upper limb movement.
Objective:
To determine the feasibility of using body-worn accelerometers to remotely assess arm movements in children with NBPP.
Design:
Criterion standard.
Setting:
Academic medical center.
Participants:
Nine adolescents with NBPP and nine age- and gender-matched control adolescents participated in the study. All were enrolled in school and participated in community activities.
Interventions:
Not applicable.
Methods:
Standard clinician-elicited measurements were collected. For assessing spontaneous arm movements, participants wore activity monitors during all waking hours for 7 days. Results were expressed as ratios of affected to unaffected arm motion for duration and magnitude and correlated with traditional clinic-based assessments. Spearman correlations were used to determine relationships between accelerometry results and traditional assessments. P-value <.05 was considered statistically significant.
Main outcome measurements:
Accelerometry measurements of arm motion and traditional clinical assessments.
Results:
Compared to control ratios, duration of arm movement and magnitude ratios were reduced in the NBPP group, particularly for arm magnitude due to reduced affected arm movement and an increase in unaffected arm movement. Ratios were highly correlated with shoulder function and, to a lesser extent, with elbow function.
Conclusions:
Real-world arm use is an appropriate outcome measure that reflects functional recovery. We demonstrate the feasibility of wearable technology to quantify duration and intensity of spontaneous arm movement in children with NBPP. Accelerometry also allows for the association between traditional clinician-elicited assessment measures and spontaneous arm movements, demonstrating the importance of the shoulder as a focus of treatment in NBPP. This article is protected by copyright. All rights reserved.
Infants that develop a neonatal brachial plexus palsy are subject to more than just a focal nerve injury. In this chapter we discuss injuries that both occur simultaneously with the NBPP and also develop along with the nerve injury over time. In order to appreciate the full impact that this has on an individual’s life, we have to look at more factors than neurological motor recovery. Through this chapter you will learn about physical, anatomic, respiratory, sensory, cognitive, and psychosocial injuries that can impact the overall outcome for children with neonatal brachial plexus palsy. With a better understanding of the multiple issues that may arise within this population, we hope to be able to care for them in a more comprehensive way.
Amaç: Ev programı, fizyoterapistler tarafından ebeveynlere tedavi seansı dışında uygulanmak üzere verilen öneriler bütünüdür. Bu çalışmanın amacı, ev programının etkinliği ve ailenin/bakım verenlerin ev programına uyumunu belirleyecek bir ölçek geliştirmekti. Yöntem: Ölçeğin geliştirilmesi için pediatrik rehabilitasyon alanındaki uzmanların klinik tecrübe ve görüşleri, aileler ile yapılan açık görüşme ve literatür taraması sonucu 48 madde belirlendi. Bu maddeler alanda en az beş yıl klinik deneyimi bulunan dört pediatrik nörolog ve yedi fizyoterapistin görüşleri temel alınarak ölçek 28 maddeye indirildi. Serebral palsili (SP) çocuk sahibi 155 ebeveyne uygulandı ve geçerlik ve güvenirlik analizleri yapıldı. Çocukların Kaba Motor Fonksiyon Sınıflandırma Sistemi, El Becerileri Sınıflandırma Sistemi, Yeme İçme Becerileri Sınıflandırma Sistemi ve İletişim Becerileri Sınıflandırma Sistemi seviyeleri belirlendi. Ebeveynlerin depresyon seviyesi Beck Depresyon Envanteri ile ölçüldü. Çocukların yaşam kalitesi, Pediatrik Veri Toplama Aracı ile değerlendirildi. Sonuçlar: Geliştirilen ölçeğin, test-tekrar test değeri ICC=0,939 ve iç tutarlılığı Cronbach alfa katsayısı=0,659 olarak bulundu. Kaba Motor Fonksiyon Sınıflandırma Sistemi seviyesi V olan SP’li bireylerin ev programına uyumu daha yüksekti (p=0,020). Tartışma: Geliştirilen “Serebral Palsili Çocukların Ebeveynlerinin Fizyoterapi ve Rehabilitasyon Ev Programına Uyumlarını Değerlendirme Ölçeği”nin geçerli ve güvenir olduğu belirlendi. Fizyoterapistler tarafından verilen ev programının etkinliği, ailenin/bakım verenlerin ev programına uyumunu belirleyecek düzeyde olduğu saptandı.
Importance
Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, “all neonatal brachial plexus palsy recovers,” “wait a year to see if recovery occurs,” and “don’t move the arm.” Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms.
Observations
Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function.
Conclusions and Relevance
Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.
Objectives: Home exercise programs are an important component of a hand therapy rehabilitation program. Compliance with the recommended home exercise regime is generally considered essential for good treatment outcomes. The aim of this pilot was to determine the clarity of an innovative hand therapy DVD. This DVD will be utilised in a randomised controlled trial (RCT) examining the usefulness of DVD technology for enhancing treatment compliance for rural and remote hand therapy patients. Methods: A series of seven DVDs of previously utilised home exercise protocols were taped and edited by the researchers. The pilot used a convenience sample of nine consecutive consenting patients who attended the Hand Therapy Service at a regional hospital in North Queensland. Subjects viewed a DVD that related to their clinical diagnosis and then completed a questionnaire on the suitability of the research instrument. Results: There were unanimously positive responses to the DVD from all subjects, with 100% indicating yes to the prompt questions. No negative comments were received. Discussion: The DVDs produced were found to be clear and useful for a group of hand therapy patients characteristically similar to those who will be recruited into the RCT. Resulting compliance with these home exercises will be presented in a subsequent paper resulting from the RCT. Given the poor health outcomes generally associated with patients from rural and remote areas, this endeavour contributes to the ongoing effort to improve service delivery to better address the health needs of rural and remote patients.
This pilot study investigated whether a home exercise video programme could improve exercise tolerance and breathlessness in patients with moderate to severe chronic obstructive pulmonary disease.
Twenty subjects completed the study after being randomized to intervention or control. The intervention group (n=10), watched a 19-min video on the benefits of exercise for patients with chronic obstructive pulmonary disease and were given a 30-min exercise video, an illustrated exercise diary and an educational booklet about chronic obstructive pulmonary disease, for use at home. They were advised to follow the exercise video programme 4 times a week for 6 weeks. The control group (n=10) received the chronic obstructive pulmonary disease educational booklet only. Exercise tolerance was measured using the Incremental Shuttle Walk Test and breathlessness by the self-reported Chronic Respiratory Questionnaire.
The median change in the Incremental Shuttle Walk Test and breathlessness score significantly improved in the intervention group compared with the control (+45 m vs -15 m, p=0.013 and +0.5 vs -0.1 Chronic Respiratory Questionnaire units, p=0.042). The other findings for the self-reported Chronic Respiratory Questionnaire showed significant improvements in the intervention group for emotion (p<0.001) and fatigue (p=0.012), but not mastery (p=0.253).
This pilot study suggests that participation in a home exercise video programme may benefit people with chronic obstructive pulmonary disease.
The purposes of this study were to determine the prevalence of and the association between shoulder contracture and osseous deformity in a cohort of children with an obstetrical brachial plexus injury and to identify the risk factors for these complications.
In a retrospective cohort study, all children with an obstetrical brachial plexus injury who had been born between January 1991 and January 1998 at one academic medical center and all those with the same diagnosis who had been born elsewhere during the same period and were referred to the medical center within six weeks after delivery were evaluated at fixed time-intervals by one examiner. The patients underwent a final orthopaedic, neurological, and radiographic examination at a mean age of 3.7 years (range, one to seven years). Shoulder contracture was defined as a decrease in the passive range of motion in one or more directions compared with the range on the unaffected side. Osseous deformity was defined as a nonspherical humeral head or an abnormal glenoid.
The prevalence of a shoulder contracture of >10 degrees was 56% (twenty-nine of fifty-two patients), and the prevalence of an osseous deformity was 33% (sixteen of forty-eight patients with complete radiographic follow-up). In the children in whom complete neurological recovery was delayed (i.e., recovery was more than three weeks after birth), the prevalence of shoulder contracture was 54% (thirteen of twenty-four patients) and the prevalence of osseous deformity was 26% (six of twenty-three patients). A strong association was noted between shoulder contracture and osseous deformity (p = 0.004). Directly after birth, the presence of a clavicular fracture was the only factor that was associated (p = 0.016) with the development of an osseous deformity (but not with a shoulder contracture). At a later stage, speed and extent of neurological recovery were related to shoulder contracture and osseous deformity. An asymmetric appearance was noticed in children who had a contracture, including those who had complete neurological recovery.
The prevalence of shoulder contracture and osseous deformity in children with obstetrical brachial plexus injury was high, even in those with complete neurological recovery. These complications were strongly associated with one another. No symptom that appeared immediately after birth was identified as a factor that would predict the development of future shoulder contracture. A clavicular fracture was found to be significantly associated with the development of an osseous deformity at a later stage.
The way we think about health and disease determines to a considerable extent what we do and say in our clinical encounters with patients. The recent publication and promotion of the World Health Organization's International Classification of Function, Health, and Disability (known as the ICF) represents an exciting new way to consider health and disease. In the context of children and youth with cerebral palsy, this model offers many heretofore ignored "point of entry" for counselling and intervention with these conditions. This model also provides many possibilities to explore research questions with a fresh approach. This article outlines the ICF model and discusses these opportunities.
Computerized educational technology, in various forms, is permeating the health care setting, and clinicians and program managers are charged with evaluating its potential to improve patient health outcomes. The purpose of this randomized controlled trial was to compare two alternative methods of therapeutic exercise instruction in a sample of orthopedic rehabilitation patients (n = 40). The traditional (control) group received routine inpatient rehabilitation exercise education from physical therapists (using demonstrations, verbal feedback, and written materials), and the technology (intervention) group received routine care as described plus one additional therapeutic session in which a customized set of exercises was downloaded from a computerized database to videotape by each patient's therapist and given to the patient for continued use at home. Data on patient compliance and patient satisfaction were collected at patient discharge and at four-week follow-up using a questionnaire designed specifically for this study. Analysis of results showed no significant differences in patient compliance or patient satisfaction between the two study groups. Results of this randomized trial suggest that computerized patient education technology may not provide the benefits anticipated.
Effective compliance with physiotherapy exercises is only possible if patients remember the exercises accurately. The purpose of this study was to assess how well elderly in-patients remembered simple physiotherapy exercises, by comparing the ability to accurately reproduce a set of exercises in a group of patients that had received a written exercise sheet, with a group that had not. The study also aimed to investigate the relationship between memory for exercises and cognition. Sixty-four in-patients in an acute hospital were taught 3 exercises. Half of the subjects were randomised to receive exercise sheets to reinforce the teaching (Group 1). The rest of the subjects did not receive this memory aid (Group 2). Two to three days later subjects were asked to demonstrate their exercises. The accurate recall of the exercises was scored using a new assessment scale with a maximum score of 24. The mean exercise score was 17.19 for group 1 (SD = 5.91) and 16.24 for Group 2 (SD = 6.01). There was no significant difference in exercise score between groups (Mann Whitney U test p = 0.44). There was a statistically significant small positive correlation between exercise score and cognition (tau = 0.263). The study showed that older adult in-patients do not remember physiotherapy exercises effectively after a single teaching session and that their memory is not significantly improved by provision of an exercise sheet.
Objective:
To investigate whether young and older adults differ in their capacity for remembering and performing physiotherapy exercises and to determine whether exercises are performed correctly.
Method:
Thirty young and 30 older (over 60 years) able-bodied adults were randomly assigned to perform and remember either a short list of five exercises or a long list of ten exercises. After a 30-minute interval, each participant was asked to perform the exercises from memory and was assessed on the number of exercises remembered and performed correctly according to a pre-determined criterion.
Results:
Younger participants correctly remembered more exercises than older participants (p < 0.001) and exercises from the short list were remembered better than exercises from the long list (p < 0.001). There was also a significant interaction between age and list length. An investigation of this interaction found that older participants showed a significant difference between exercises correctly remembered from the short and long lists (p < 0.001) but younger participants did not (p = 0.11). There was also no significant difference between young and older participants' memory for exercises from the short list (p = 0.39), but there was a difference in their memory for exercises from the long list (p < 0.001).
Conclusions:
Exercises were forgotten or incorrectly performed by both young and old. Older people forgot more (11 % short list; 37% long list) than the younger (7% short list; 15% long list) and were significantly disadvantaged when learning the longer list of exercises. This should be taken into account when teaching home exercises and it is recommended that, particularly for older patients, the number of exercises taught be kept to a minimum. Further studies of memory for home exercises are needed in the clinical environment, particularly to evaluate the benefits of written information sheets.
This study compared videotape instruction (dynamic modeling) to instruction via still-photograph illustrations (static modeling) for influencing the quality of performance, motivation, and confidence of subjects performing common simple and complex exercises. Ten male and ten female subjects were randomly assigned to either a static or dynamic demonstration group. Subjects were scheduled for an acquisition session and retention test 24 hours apart. In acquisition, subjects viewed the static or dynamic model before performing four trials of each exercise. In the retention test, modeling was absent and subjects had to recall the exercises from memory in order to perform. Subjects were videotaped performing the exercises in acquisition and retention for subsequent rating of form by two raters independently. After the retention test, subjects viewed the alternative mode of modeling and were surveyed about the mode they found most motivating, and the mode engendering the most confidence about performing the exercises correctly. Analysis of form rating scores indicated the dynamic group to have significantly higher ratings of form in both acquisition and retention. The survey indicated that the dynamic group was more motivated to perform the exercises in a home environment, and more confident about performing the exercises correctly. Additionally, all subjects indicated a preference for using videotape over illustrations to learn the exercises. The findings suggested dynamic modeling via videotape was more effective than static illustrations for promoting correct form for the exercises. In addition, videotape modeling was indicated as more appropriate for encouraging confidence and motivation in an unsupervised exercise environment, such as a home exercise program.
Aim: Home programmes are used extensively for children with cerebral palsy. Even though there is consensus about the importance of home programme intervention, there is little evidence of efficacy and scant information regarding programme characteristics that might affect family participation. Instead, research to date has focussed on parental compliance with prescribed programmes and parent–child interactions.
Methods: Based on reviewed literature, this article proposes a model to guide development of home programmes for children with cerebral palsy. It is a starting point for therapists to consider the way in which they focus and structure their home programmes for children who have cerebral palsy.
Results and Conclusions: The paper identifies an urgent need to develop clinical guidelines for home programmes through rigorous formal processes and to evaluate the impact of occupational therapy home programmes.
To investigate the impact of a video-based educational resource on home exercise compliance among caregivers of children with neonatal brachial plexus palsy (NBPP).
Retrospective analysis of self-reported caregiver home exercise habits and resultant shoulder range of motion (ROM) and biceps power in patients with NBPP.
Home-based exercise program.
Adult caregivers of children with NBPP followed up through the Brachial Plexus Program at the University of Michigan (N = 83 surveyed initially, with N = 37 completing the final survey).
Caregivers completed surveys before and approximately 3, 6, and 12 months (times A, B, and C, respectively) after receiving the "Home Exercise Therapy Program for Brachial Plexus Palsy" digital video disk (DVD). A retrospective analysis of shoulder ROM and biceps power of patients was completed as representative of arm function during the study.
Surveys assessed home exercise compliance, resources used to guide exercises, and caregiver confidence in the correctness of exercises being performed. Functional outcomes analyzed include biceps strength and shoulder active and passive ROM.
Home exercise compliance increased from 74% initially to 96% at time A (P < .001), remained at 94% at time B (P < .001), and fell to 84% at time C (P = .016). Use of the DVD to guide home exercise decreased from 69% at time A to 57% at time B and C (P = .026). After receiving the DVD, exercise frequency and caregiver confidence increased. Although some measures of shoulder active ROM and biceps power improved during the course of the study, there was no consistent statistically significant relationship between increased caregiver confidence and functional outcomes. No causal relationship exists between DVD content and functional status at this time.
As the first formal evaluation of a video-based resource guiding exercise therapy for children with NBPP, we suggest that this population may be receptive to alternative media and may benefit from dynamic modeling of home exercises.
The nationwide incidence of neonatal brachial plexus palsy in the United States is unknown. The purpose of this study was to determine the incidence of this condition in the United States and to identify potential risk factors for neonatal brachial plexus palsy.
Data from the 1997, 2000, and 2003 Kids' Inpatient Database data sets were utilized for this study. Patients were identified with use of the International Classification of Diseases, Ninth Revision (ICD-9), code 767.6 for neonatal brachial plexus palsy. Previously reported risk factors for this condition, including shoulder dystocia, instrumented delivery, breech delivery, an exceptionally large baby (>4.5 kg), heavy infant weight for gestational dates, multiple birth mates, and cesarean delivery, were also identified with use of ICD-9 codes. Multivariate logistic regression analysis was utilized to assess the association of neonatal brachial plexus palsy with its risk factors, after adjusting for sociodemographic characteristics, such as gender, race, and payer status; hospital-based characteristics, such as number of hospital beds, hospital location, region, type, and teaching status; and the effect of time.
Over eleven million births were recorded in the database, and 17,334 had a documented brachial plexus injury in the total of three years, yielding a nationwide mean and standard error of incidence of neonatal brachial plexus palsy in the United States of at least 1.51 +/- 0.02 cases per 1000 live births. The incidence of this condition has shown a significant decrease over the years (p < 0.01). In the multivariate analysis, shoulder dystocia had a 100 times greater risk, an exceptionally large baby (>4.5 kg) had a fourteen times greater risk, and forceps delivery had a nine times greater risk for injury. Having a twin or multiple birth mates and delivery by cesarean section had a protective effect against the occurrence of neonatal brachial plexus palsy. Forty-six percent of all children with neonatal brachial plexus palsy had one or more known risk factors, and fifty-four percent had no known risk factors.
This nationwide study of neonatal brachial plexus palsy in the United States demonstrates a decreasing incidence over time. Shoulder dystocia poses the greatest risk for brachial plexus injury, and having a twin or multiple birth mates and delivery by cesarean section are associated with a protective effect against injury. Most children with neonatal brachial plexus palsy did not have known risk factors.
The aim of this study was to design a theory-based educational program for adolescents with inflammatory bowel disease (IBD) using an interactive multimedia CD-ROM and to test its effectiveness in improving knowledge in IBD.
Curriculum-based instruction using educational theory and principles was designed for adolescents on an interactive multimedia CD-ROM. Twenty subjects completed summative evaluation of the CD-ROM measuring gain in knowledge about IBD immediately and 9 months after instruction.
Subjects found the CD-ROM to be informative, appealing, and easy to use. The mean baseline score of the adolescents on the Crohn's and Colitis Knowledge questionnaire was 12.2 (standard deviation 5.14, range 3-24). After an average of 30 minutes of self-directed learning, adolescent subjects increased their posttest score to a mean of 19.8, a gain of 7.6 points over baseline (95% confidence interval 5.2-10.1, P < 0.0001). Knowledge of medications, disease complications, and gastrointestinal structure and function was gained and retained upon retesting at 9 months with a mean Crohn's and Colitis Knowledge questionnaire score of 17.5 (standard deviation 3.9, range 12-26), which was still an improvement over the mean pretest knowledge score of 12.2 (P < 0.001).
Adolescents with IBD have low baseline knowledge about their disease. A rigorously developed interactive educational tool is now available for instructing adolescent patients about their IBD.
Internal rotation contracture of the shoulder is common in children with neonatal brachial plexus palsy. A long-standing contracture may cause osseous deformities in the developing shoulder. The purpose of the study was to evaluate the relationship between osseous deformities of the glenohumeral joint and structural differences due to muscle denervation in the rotator cuff muscles.
One hundred and two children with residual neonatal brachial plexus palsy underwent magnetic resonance imaging of both shoulders. The glenoid version and posterior, medial, and superior subluxation of the humeral head were measured. The shapes of the glenoid and the humeral head were categorized, and the infraspinatus, supraspinatus, subscapularis, and deltoid muscles were scored as being normal, atrophic, or atrophic with fatty degeneration.
Muscle degeneration was most prominent in the subscapularis muscle. Glenoid version correlated with the structural differences in the subscapularis muscle. Posterior subluxation of the humeral head and the shape of the glenoid correlated with all abnormal rotator cuff muscles. Superior humeral subluxation correlated only with changes in the supraspinatus muscle. Medialization and the shape of the humeral head were not associated with atrophic changes of the rotator cuff. Regeneration of the rotator cuff muscles was not significantly different in patients with a C5-C6 (C7) or a complete brachial plexus lesion. However, the changes in glenoid version, the degree of posterior humeral subluxation, and the degree of medial humeral subluxation were significantly more severe in patients with a C5-C6 (C7) lesion compared with those in patients with a complete lesion of the brachial plexus.
Structural differences in the rotator cuff muscles alter the direction of the humeral head forces on the developing glenoid fossa and can lead to osseous deformities. Glenohumeral deformities are significantly greater with a C5-C6 (C7) lesion than with a complete brachial plexus lesion in which the large internal rotators are also affected. Reducing the muscular imbalance that occurs with a C5-C6 (C7) lesion could diminish glenohumeral joint incongruency and may improve the outcome of subsequent soft-tissue release or tendon transfer surgery.
To determine the neuromuscular outcomes of an eccentric strength-training programme for children and adolescents with cerebral palsy (CP).
In this randomised, parallel-group trial with waiting control, 14 participants with CP (six males, eight females; mean age 11y, SD 2y range 9-15y), diagnosed with upper-limb spasticity were compared with 14 age- and sex-matched typically developing participants. Participants with CP completed a 6-week progressive resistance-strengthening programme, performing eccentric lengthening contractions of their upper limb three times a week. Data from dynamometer and surface electromyography (EMG) assessments included peak torque normalised to body mass (T/Bm), work normalised to body mass (W/Bm), angle at peak torque, curve width, and EMG activation.
After training, children with CP had improved eccentric T/Bm (p=0.009) and W/Bm (p=0.009) to a level similar to that of the typically developing children. No change in angle of peak torque occurred, although curve width increased both concentrically (p=0.018) and eccentrically (p=0.015). EMG activity was elevated before training in children with CP but decreased with training to levels similar to those of the typically developing children.
With eccentric strength training, children with CP increased torque throughout range of motion. Results suggest that eccentric exercises may decrease co-contraction, improving net torque development. Eccentric actions may be important in the maintenance of the torque-angle relationship. These results have significant implications for the prescription of strength-training programmes for people with CP.
The National Health Service is developing an ethos of self-care. Patients are being encouraged to become proficient in helping themselves. This has long been a philosophy of the physiotherapy profession, where self-care between consultations has been an integral part of the treatment process through encouraging the uptake of self-care skills training. This study explored how patients with shoulder and back pain perceived videotaped exercises and instructions to support their routine physiotherapy, and how the videotape was used.
A videotape, developed by physiotherapists for patients with musculoskeletal problems, of exercises to view at home was given to patients by their physiotherapists to support their routine physiotherapy consultations. A qualitative methodology was used to examine how patients responded to being given a videotape of exercises and instructions between consultations. Data were collected through semi-structured interviews.
The study was based in 26 general practices that had access to practice-based physiotherapists in two primary care trusts in the north-west of England.
Thirty-three patients with shoulder and back pain who received a videotape of exercises and advice were interviewed.
Three themes emerged from the data: finding space for exercise; remembering and doing exercises; and supporting the physiotherapy-patient relationship. Patients discussed aspects of motivation, and described how a videotape of exercises might support or inhibit the performance of exercises prescribed by physiotherapists. Patients identified a range of different ways in which they derived support from the videotape.
The videotape supported patients with a variety of different needs as it enhanced their ability to complete exercises correctly. Videotapes (or DVDs) are useful for patients and could be adopted as a tool to support treatment.
Home-based exercise is a viable solution for frail elderly individuals with difficulties in reaching exercise facilities outside home. The aim of this study was to determine the effects of a home-based video exercise program on physiological performance, functional capacity and health-related quality of life.
Community-dwelling frail women > or = 75 yrs, receiving public home care, were randomized into a training group (n=30) and a control group (n=31). Participants exercised for 26 minutes, three times per week for five months. Both groups received a bi-weekly telephone call. The effect of intervention was evaluated by the physical performance test, mobility-tiredness score, maximal isometric handgrip and biceps strength, lower limb explosive power, repeated chair rise (5 times), 10-m maximal walking-speed, semi-tandem balance, and health-related quality of life, as measured by EQ-5D and self-rated health.
Twenty-five participants (83%) in the training group and 28 (90%) in the control group completed the project. Adherence to the training protocol was on average 89.2%. At follow-up, between-group analysis revealed a significant difference only in EQ-5D (valued by time-trade-off tariffs), resulting from a significant decrease observed in the control group and a trend towards an increase in the training group (p=0.082). Significant within-group improvements, ranging from 8-35%, were also observed for the physical performance test, mobility-tiredness score, handgrip, biceps strength, chair rise, and 10-m maximal walking-speed in the training group, and for walking-speed and self-rated health in the control group.
These results suggest that home-based training for frail older women using an exercise video induces lasting health-related quality-of-life (EQ- 5D). In addition, a tendency towards improvements in physiological performance and functional capacity was observed.
Sixty-one cases of brachial plexus birth palsies were documented in 30,451 live births at Kaiser Foundation Hospital, San Francisco, between January 1972 and December 1982, for an incidence of 2.0/1,000 births. Thirty-eight patients were evaluated in follow-up ranging from 1 year to 11 years 6 months. Associated birth traumas include facial palsy, clavicle fracture, arm ecchymosis, and cephalohematoma. The prognosis was excellent, with full recovery in 95.7% of cases. The presence of a palsy did not preclude the development of dominant use of the extremity. Right-handedness was noted in 73% of right-sided palsies. This study showed that the incidence of palsies has not declined in the past 10 years. Risk factors and associated birth injuries were similar to those in other reports. The severity of palsies has lessened, and early recovery is usual.
The purpose of this study was to investigate whether the mode of teaching exercises (use of brochures versus therapist teaching) affects whether patients correctly perform the exercises and whether it affects changes in impairment.
Eighty-seven patients (33 women, 54 men) with neck pain and low back pain were examined. The average age was 48 years (SD = 12.7, range = 21-67).
Two groups of patients were analyzed. The supervised (physical therapist-instructed) group (n = 47) exercised under the supervision of a physical therapist, whereas the brochure group (n = 40) received their instructions only from one of three brochures. A rating scale was used to assess the correctness of exercise performance. Muscle status was registered using a standardized procedure for determination of muscle force and length. Pain severity was determined by means of a visual analogue scale.
On the rating scale evaluating the correctness of exercise performance at follow-up, the patients in the supervised group performed better than the patients in the brochure group. In addition, there was a strong correlation between the quality of exercise performance and decrease in pain.
Exercises learned only from a brochure without being monitored by a physical therapist were done properly by only about half of the patients and appeared to result in fewer improvements in impairments.
To compare the effects of preadmission and postadmission educational programs for patients with total knee arthroplasty.
Quasiexperimental study.
60 total knee arthroplasty patients.
Subjects in the experimental group received preadmission preoperative teaching with an instruction booklet during a preoperative outpatient clinic visit. Upon admission to the hospital, they were presented with an educational video tape. The control group received only postadmission preoperative teaching with the same instruction booklet and no video. PREADMISSION AND POSTADMISSION: Preoperative anxiety level, knowledge about postoperative care, exercise performance and postoperative recovery were used as outcome measures.
The research results found: 1. there was no significant difference between the two groups in reduction of preoperative anxiety score: 2. the experimental group had a significantly higher knowledge level than the control group; 3. the experimental group performed exercise more regularly and correctly than those in the control group; 4. the experimental group had greater flexion of the operative knee joint than the control group.
Preadmission teaching with a videotape program and a health manual for patients with total knee arthroplasty is recommended.
More indicators such as postoperative pain and patient satisfaction can be used to investigate the effectiveness of intervention. In addition, increasing the sample size is recommended for future studies.
Many children who sustain birth injuries to the brachial plexus suffer significant functional limitations due to various sequelae affecting the shoulder and elbow or forearm. The maintenance of full passive mobility during the period of neurological recovery is essential for normal joint development. Early surgical correction of shoulder contractures and subluxations reduces permanent deformity. Reconstruction of forearm rotation contractures significantly improves the appearance and use of the extremity for many basic activities. Each child must be carefully evaluated, therapy maximized, and the surgical approach individualized to obtain the best result.
The incidence of obstetric brachial plexus injury (OBPI) was investigated and the natural course of this disorder and the frequency of shoulder contracture described. Between 1988 and 1997 13,366 children with a gestational age of 30 weeks or more, were born at the Academic Medical Center, Amsterdam. Of these, 62 had an OBPI (4.6 per 1000). Complete neurological recovery occurred in 72.6% of cases. Half of them had a delayed recovery of more than three weeks (mean recovery time 6.2 +/- 3.1 months). Shoulder contracture occurred in at least one-third of the children with delayed recovery and in at least two-thirds of the children with incomplete recovery. The incidence of OBPI in our hospital was found to be higher and to have a less favourable natural course than is usually reported in the literature. Contracture of the shoulder joint is frequently found even in infants with complete neurological recovery.
Changes in health care delivery in the United States of America due to economic pressures have required nurses to develop innovative instructional materials for educating patients and families. Educational materials such as videotapes, specifically designed to provide information and promote active participation in treatment decisions, can be effective tools for empowering patients. A comprehensive analysis in 1988 concluded that the concept of 'video modelling' or 'behavioural modelling' offered the greatest benefit of videotaped presentations.
The purpose of this integrative literature review was to examine the concept of video modelling and its applications in clinical practice.
A computer search of the electronic databases of Medline and CINHAL between 1990 and 1999 produced a total of 40 research studies on video instruction for patients. Based on criteria for inclusion, 18 research studies involving video modelling were reviewed and three major uses were identified: (1) assisting decision making regarding treatment options; (2) reducing pre-procedural anxiety and improving coping skills; and (3) teaching self-care practices.
The studies reviewed included a variety of research designs, clinical settings, and patient populations. Despite these differences, several benefits to the use of video modelling were found. Patients who viewed videotapes regarding treatment options had a greater understanding of the risks and benefits of those choices and were more apt to be active participants in decision making. Collective results of the studies focusing on stress and coping revealed that preparatory videotapes using video modelling could have a positive effect on reducing anxiety and physiological arousal during stressful procedures. With self-care practices, several of the studies found that there was an increase in desired behaviours in people whose educational programmes included video modelling.
The use of video modelling has potential benefits for clinical practice in facilitating knowledge acquisition, reducing preparatory anxiety, and improving self-care. Nurses must become more actively involved in evaluating various teaching approaches used with patients to enhance practice and outcomes.
Today's health care environment encourages cost containment in many aspects of patient care, including exercise instruction in physical therapy. The purpose of this study was to determine whether different modes of instruction affect the learning of an exercise program, as measured by retention test performance immediately after the instruction and practice and after a 1-day delay.
Subjects were 40 people, aged 26 to 51 years (mean=38.4, SD=7.4), with no known shoulder pathology.
Subjects were instructed in a series of 5 shoulder exercises by 1 of 4 modes of instruction: (1) live modeling, (2) corrected-error videotape, (3) error-free videotape, and (4) handout alone.
Subjects who received instruction from handout materials alone (handout group) exhibited poorer performance accuracy than subjects who received live or videotaped modeling and exercise instruction. In addition, the total number of errors of the handout group was more than twice the average of the live instruction and videotape instruction groups. No differences were found between the live instruction group and the 2 groups that received videotaped instruction.
Live and videotaped modeling are more effective than a handout alone for achieving performance accuracy of a basic exercise program, as measured by immediate and delayed retention tests.
This manuscript will review the literature and focus on the present controversies regarding natural history, microsurgical treatment, and secondary shoulder reconstructive surgery in infants with brachial plexus birth palsies. Surgical indications, expected outcomes and complications will be addressed. The controversy regarding microsurgery timing in extra-foraminal ruptures will be addressed in detail. The developments in assessment and care of glenohumeral deformity with magnetic resonance imaging scans, arthroscopic and open reductions, and tendon transfers about the shoulder will be discussed. Recommendations for microsurgery and shoulder reconstruction will be based on the present evidence from the literature.
Obstetrical brachial plexus palsy, one of the most complex peripheral nerve injuries, presents as an injury during the neonatal period. The majority of the children recover with either no deficit or a minor functional deficit, but it is almost certain that some will not regain adequate limb function. These few cases must be managed in an optimal way. Considerable medical and legal debate has surrounded the etiologic factors of this traumatic lesion, and obstetricians are often considered responsible for the injury. According to recent studies, spontaneous endogenous forces may contribute substantially to this type of neonatal trauma. All obstetric circumstances that predispose to brachial plexus damage and that could be anticipated should be assessed. Correct diagnosis is necessary for the accurate estimation of prognosis and treatment. The most important aspect of therapy is timely recognition and referral, to prevent the various possible sequelae affecting the shoulder, elbow, or forearm. Since the early 1990s, research has increased the understanding of obstetrical brachial plexus palsy. Further research is needed, focused on developing strategies to predict brachial injury. This review focuses on emerging data relating to obstetrical brachial plexus palsy and discusses the present controversies regarding natural history, prognosis, and treatment in infants with brachial plexus birth palsies.
Natural history of obstetric brachial plexus palsy: A systematic review
- Pondaag
An investigation into younger and older adults' memory for physiotherapy exercises
- Rastall