docAngela Shierk, OTR, PhD Texas Scottish Rite Hospital for Children
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Angela Shierk, OTR, PhD Texas Scottish Rite Hospital for Children
Angela Shierk, OTR, PhD Texas Scottish Rite Hospital for Children No disclosures Overview of Course TSRHC Terminology, Diagnosis, and Upper Extremity Anatomy Evaluation Part 1: Body Function and Structure Evaluation Part 2: Activity and Participation Surgical Interventions Therapeutic Interventions Implementing Effective Home Programs NBPP Taxonomy-Driven Classification Texas Scottish Rite Hospital for Children Treating pediatric orthopedic conditions for over 90 years Scoliosis and spine Clubfoot and foot disorders Hip Dysplasia and Perthes Limb length discrepancies Hand disorders Also treat Pediatric Developmental Disabilities, Dyslexia, Neurological conditions www.tsrh.org NBPP Clinic: Interdisciplinary Team Pediatric Hand Surgeons Pediatric Neurosurgeons Pediatric Neurologists Physician Assistant Hand Surgery Fellows Nurse Coordinator Occupational Therapists Physical Therapists Research Coordinator Psychologist Child Life Specialist Administrative Staff Media Community Based Therapists Parents and Family Role of Therapist in Clinic Setting Provide ongoing assessment and intervention as the patient presents to be seen by a hand surgeon Intervention primarily consists of home programs and education to the patient and family Assist physician in determining future medical/surgical considerations & efficacy of current interventions Recommend referrals and communication to hospital based or community based services Terminology Terminology Neonatal – Relating to a newborn infant Brachial- Pertaining to the arm Plexus- A network of nerves Palsy- Weakness temporary or permanent loss of sensation or ability to move Wilhelm Heinrich Erb 1873 Described upper plexus palsy in an adult Localized the lesion to the junction of C5 and C6 – “Erb’s Point” (Ezaki, 2013) Augusta Klumpke 1885 Described lower plexus palsy Noted pupillary signs – sympathetic nerve involvement (Ezaki, 2013) Other Terminology Erb’s Palsy Klumpke’s Palsy Obstetric Brachial Plexus Palsy Birth Brachial Plexus Palsy Brachial Plexus Injury other Reports of NBPP Following spontaneous vaginal deliveries without trauma or shoulder dystocia suggesting pre-existing plexopathy or causation by natural labor mechanics (Gherman 1999, Jennett 1992, Medlock 1997) After caesarian section delivery (AlQuattam 1996, Gherman 1998, Scheller 1994) Diagnosis NBPP Diagnosis An injury to the brachial plexus, C5-T1, that occurs before or during the birth process Mechanism is traction across plexus Most common cause of stretch are the forces produced during labor Incidence of NBPP Remains between 0.3 and 2.5 per 1000 live births Reported incidence varies with Definition of plexopathy Referral patterns Median incidence for newborns: Less than 4000g (<8lbs 13oz) is 0.9 per 1000 births 4000g-4500g (8lbs 13oz - 9lbs 14oz) is 1.8 per 1000 births More than 4500g (>9lbs 14oz) is 2.5 per 1000 births Risk Factors Large birth weight Shoulder dystocia Prolonged labor Assisted delivery Breech presentation Difficult delivery Excessive maternal weight gain Gestational diabetes Maternal multiparity Previous births with BPP Birth weight and shoulder dystocia are not predictable Gross TL, Sokol RJ, Williams T, and Thompson K: Shoulder dystocia: A fetal-physician risk. Am J Obstet Gynecol 156: 1408-1419, 1987. Gross, et.al. 7,123 deliveries, 116 cases of S.D. 49 S.D. in 394 babies > 4,000 grams (>8lbs 13oz) (345 had no S.D.) 67 S.D. in babies < 4,000 grams (<8lbs 13oz) Gross, et.al. Birth weight estimated by ratio femoral length / abdominal circumference If BW could be predicted and Caesarian delivery for >4,500 g, calculated that 978 C sections would be done to prevent one persistent plexus injury Gross, et.al. 49 cases of shoulder dystocia (>4000 g) 29 had no trauma 20 had trauma 12 clavicle fractures - no neuro injury 1 humerus fracture - no neuro injury 9 transient Erb’s palsy - resolved 1 BPP with permanent sequelae Initial Presentation Focus on recovery and improving function Child with a weak arm Decreased spontaneous movement Asymmetric infantile reflexes Narakas Classification Narakas 1 – C5 and C6 (Erb’s Palsy) Weakness of shoulder abductors, external rotators, elbow flexors, wrist extensors Narakas 2 – C5, C6 and C7 also involved Weakness also in elbow extensors and shoulder adductors Narakas 3 – Pan plexus without Horner’s syndrome Narakas 4 – Total plexus with Horner’s syndrome Horner’s Syndrome Interruption of oculosympathetic nerve supply Miosis Ptosis Loss of hemifacial sweating Good Prognostic Signs Normal eyes - no Horner’s syndrome No cranial trauma Clavicle fracture Upper plexus partial lesion Early spontaneous recovery Poor Prognostic Signs Horner’s syndrome Pan plexus involvement Cranial trauma Shoulder trauma Cool, dry limb Absence of early recovery Palpable neuroma Anatomy Review Anatomy – Brachial Plexus It doesn’t really look like this. . . Anatomy – macerated specimen (Kerr) Variability in Plexus anatomy Tountas et al. Anatomic Variations Pirates’ Rules Shoulder C5 Shoulder Flexion Deltoid (anterior portion) Coracobrachialis Shoulder Extension Latissimus Dorsi Teres Major Deltoid (posterior portion) Shoulder Abduction Deltoid (middle portion) Supraspinatus Shoulder Adduction Pectoralis Major Latissimus Dorsi C6 C7 C8 T1 Shoulder C5 External Rotation Infraspinatus Teres Major Internal Rotation Subscapular Pectoralis Major Latissimus Dorsi Teres Major Scapular Retraction Rhomboid Major Rhommboid Minor Scapular Protraction Serratus Anterior C6 C7 C8 T1 Elbow and Forearm C5 Elbow Flexion Brachialis Biceps (forearm supinated) Elbow Extension Triceps Supination Biceps Supinator Pronation Pronator Teres Pronator Quadratus C6 C7 C8 T1 Wrist C5 Wrist Extension Extensor carpi radialis longus Extensor carpi radialis brevis Extensor carpi ulnaris Wrist Flexion Flexor carpi radialis Flexor carpi ulnaris C6 C7 C8 T1 Fingers and Thumb C5 Finger Extension Extensor digitorum communis Extensor indicis Extensor digiti minimi Finger Flexion Flexor digitorum profundus Flexor digitorum superficialis Lumbricals Thumb Extension Extensor pollicis brevis Extensor pollicis longus Thumb Flexion Flexor pollicis brevis Flexor pollicis longus C6 C7 C8 T1 Part 1 Evaluation: Overview History and Subjective Shoulder Joint Clinical Exam Sonogram Passive Range of Motion Shoulder External Rotation Elbow Extension Standard Measurements Scapular Humeral Angles Active Range of Motion Infantile Reflexes Active Movement Scale Modified Mallet Scale Standard Measurements Strength Grip and Pinch Sensation Semmes Weinstein Stereognosis Pain Wong-Baker FACES Interview Example of Examination Form – Handout History and Subjective Labor/pregnancy Birth weight Initial appearance and function of limb Humeral or clavicle fracture Dates of function recovery Patient and parent concerns Shoulder Joint Clinical Exam - Shoulder Observation Position of arm at rest Signs of shoulder dislocation Ages 0-18 years, primary focus for ages 0-12 months Signs of Shoulder Dislocation Loss of passive external rotation Apparent shortening of humerus Skin fold asymmetry Deep axilla Palpable humeral head posteriorly Ages 0-18 years, primary focus for ages 0-12 months Loss of Passive External Rotation Loss of Passive External Rotation Loss of External Rotation Older Child Rapid Loss of PER 100 80 60 40 20 0 M-5 -20 -40 M-4 M-3 Months prior to diagnosis M-2 M-1 M0 Apparent Shortening of Humerus Apparent Shortening of the Humerus Older Child Skin Fold Asymmetry Deep Axilla Deep Axilla Older Child Deep axilla Sonogram Used to diagnose Shoulder subluxation/dislocation Clavicular fractures Humeral fractures Radial head dislocations Sonography preferred in infants b/c no radiation or need for sedation X-ray, CT, or MRI will also show position of the joint Why important? Early identification - to avoid long term deformity of the joint 7 year old child Under-estimated 13 cases reported : 4 ant, 9 post Anterior : Posterior : 1953 Liebolt 1 1980 May 1968 Babbit 2 1989 Dunkerton 1 1997 Flores 1 1993 Troum 2 1998 Torode 4 1998 Hunter 1 1 1 Fairbank - 1913 28 cases of early subluxation of the shoulder Youngest age 2 months Described the mechanism Operated to reduce TSRHC Findings Prevalence : 9 % (134 new NBPP, 12 posterior shoulder dislocations ) Average age at discovery : 6 months ( 3 to 10 months ) Sex : 7 boys, 5 girls Side : 6 right, 6 left (Ezaki, 2013) Neurological Level C5-T1 C5-C6 C5-C6 C5-C7 C5-T1 C5-C7 (Ezaki, 2013) Take Home Message Approximately 10% of babies with NBPP will develop enough muscle imbalance to posteriorly dislocate the involved shoulder Unopposed internal rotation posterior subluxation Passive Range of Motion Shoulder External Rotation Arm aDducted Elbow flexed at 90 degrees Stationary arm: perpendicular to the trunk Moving arm: parallel to forearm Ages 0-18 years Elbow Extension Monitor over time, prevalence of elbow flexion contractures Ages 0-18 years Standard Measurements PROM Shoulder Flexion Extension Abduction Adduction Internal Rotation External Rotation Elbow Flexion Extension Forearm Supination Pronation Wrist Flexion Extension Fingers Flexion Extension Thumb Flexion Extension Abduction Ages 0-18 years Scapular Humeral Angles Horizontal ADduction Move arm from horizontal aBduction into horizontal aDduction Feel for medial border of scapula ~ 100 degrees Ages 0-18 years Scapular Humeral Angles ADduction With scapula aligned with frontal plane measure angle between lateral border of scapula and humerus ~ 40 degrees Ages 0-18 years Scapular Humeral Angles ABduction Move arm from aDduction into aBduction Feel for lateral border of scapula Measure angle between lateral border of scapula and humerus ~ 150 degrees Ages 0-18 years Practice Scapular Humeral Angles See handout Shoulder External Rotation with arm aDducted Active Range of Motion Infantile Reflexes Reflex actions originating in the central nervous system exhibited by normal infants in response to a particular stimuli Disappear or are integrated as child moves through normal child development Can be used in the first few months of life to assess AROM Ages 0-6 months The Moro Reflex The “startle response” Present at birth Peaks at one month Begins to integrate at 2 months Used to assess shoulder ROM Palmar Grasp Relfex Presents at birth Persists until 5-6 months Used to assess finger flexion ATNR Reflex Asymmetric Tonic Neck Reflex Fencing Posture Present at one month Integrates at 4 months Used to assess elbow flexion Active Movement Scale Developed at the Hospital for Sick Children, Toronto, Ontario Ordinal, 8-grade scale Does not require that children perform tasks on command Evaluates overall joint movements Spontaneous movement Curtis, et al., 2002 Ages 0-4 years, or until child can follow directions for AROM Active Movement Scale Gravity Eliminated Against Gravity 5: Less than 50% motion 0: No contraction 1: Contraction, No motion 6: Greater than 50% motion 7: Full motion 2: Less than 50% motion 3: Greater than 50% motion 4: Full motion Guidelines for Use - AMS A score of 4 must be achieved before a higher score can be assigned Movement grades are assigned within the available PROM Finger flexion/extension is assessed at the MP joints Digital flexion or extension is given a single grade using the score of the best finger Assessment Assistants Clear Rain stick – visual/auditory (babies) Bubbles (babies and toddlers) Key Chain Gadgets (toddlers) Mr. Potato Head (toddlers and school age) AMS Video AMS Scores Modified Mallet Classification Classifies shoulder function in children Assesses the child’s ability to perform functional movements of the affected extremity Child must be able to follow commands Scoring Ordinal, 5-grade scale (van der Sluijs, et al., 2006) Ages 3-18 years, or when child can follow directions Modified Mallet Classification Modified Mallet Classification Mallet Scores Standard Measurements - AROM Shoulder Flexion Extension Abduction Adduction Internal Rotation External Rotation Elbow Flexion Extension Forearm Supination Pronation Wrist Flexion Extension Fingers Flexion Extension Thumb Flexion Extension Abduction Ages 4-18 years, or when child can follow directions Active Range of Motion Strength Grip and Pinch Lateral Pinch Grip Tip Pinch Tripod Ages 6-18 years, or when child can follow directions Sensation Semmes Weinstein Ages 6-18 years, or when child can follow directions Stereognosis Ages 6-18 years, or when child can follow directions Finger Biting Ages 0-18 years, primary focus infants and toddlers Pain Wong-Baker FACES Ages 3-18 years Pain Interview Where is the pain? Point to it with one finger Can the child rate the pain? What does it feel like? How long does it last? How often? What starts it? What stops it? Comments Ages 5-18 years, younger children ask parents Part 2 Evaluation: Overview Developmental and Functional Checklist Ages and Stages Questionnaire (ASQ) Pediatric Evaluation of Disability Inventory (PEDI) Pediatric Outcomes Data Collection Instrument (PODCI) Canadian Occupational Performance Measure (COPM) Children’s Hand-use Experience Questionnaire (CHEQ) Assisting Hand Assessment (AHA) Developmental and Functional Checklist Developmental and Functional Checklist Type: screener developed at TSRHC for patients with unilateral UE involvement Age Range: 0-18 years Source: Included in resources Task 0-12 months Turns head L/R equally (0-2 mo) Prone head lift to 45 degrees (0-3 mo) Hands toward midline (1-4 mo) Grasp/transfer objects (4-6 mo) Rolling (prone/supine (5-8 mo) Sitting (5-8 mo) Reaches to mouth while sitting - involved UE (6 mo) Holds bottle and brings to mouth 2 hands (6 mo-10 mo) Crawling (8-10 mo) Holds arm out for coat/open front shirt involved UE (9 mo) Pulling to stand (9-12 mo) Feeds self finger foods pincer grasp - involved UE (10-12 mo) Removes unbuttoned coat (12 mo) 12-24 months (1-2 yrs) Throw a small ball with forward arm motion – involved UE (12-18 mo) Ambulating (12-18 mo) Stacks small block or toy on top of another one – involved UE (14-18 mo) Removes mittens (14 mo) Removes socks on request (2 yrs) Removes untied/unfastened shoes (2 yrs) Helps push down pants (2 yrs) Established / Independent Emerging / Needs Assistance Unable / Dependent No Uses an Assistive Opportunity / Device or NonNot Expected involved UE Self Care and Hand Function Ages and Stages Questionnaire (ASQ) ASQ-3 Type: Developmental Screener Communication Gross motor Fine motor Problem solving Personal-social Age Range: 1-66 months Source: http://agesandstages.com/ Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) PEDI-CAT Type: Computer based assessment: Daily Activities Mobility Social/Cognition Responsibility Age Range: Birth-20 years Source: http://pedicat.com/category/home/ Pediatric Outcomes Data Collection Instrument (PODCI) PODCI Type: Questionnaire to assess overall health pain ability to participate in normal daily activities vigorous activities associated with young people Age Range: Child 2-10 years, adolescent 11-18 years Source: http://www.aaos.org/research/outcomes/outcomes_peds.a sp Canadian Occupational Performance Measure (COPM) COPM Type: Semi-structured interview Client’s perception of occupational performance Self care Productivity Leisure Age Range: all ages Source: http://www.caot.ca/copm/ Children’s Hand-use Experience Questionnaire (CHEQ) CHEQ Type: Computer based questionnaire Unilateral limitations Bimanual activities Age Range: 6-18 years Source: http://www.cheq.se/ Assisting Hand Assessment (AHA) AHA Type: assess hand function (unilateral) during bimanual play – video based Age Range: 18 months-12 years Mini AHA 6 months-18 months AHA-ABI AHA-ULRD Ad-AHA Source: http://www.ahanetwork.se/ AHA Video AHA Score Sum: Scaled score %: 73 77 Goal Areas: -Moves Upper Arm -Grasps with Assisting Hand -Moves Forearm -Puts Down / Releases with Assisting Hand Diagnosis and Evaluation: Discussion, Question & Answer Natural History All babies with NBPP show at least some improvement from initial presentation Usually healthy otherwise and do not have developmental delay based on central neurological problem Depends on anatomic level and severity Almost 60% make a full spontaneous recovery by 2 months Antigravity biceps at 2 months suggests complete recovery in the first 2 years No antigravity biceps function by 5-6 months may benefit from brachial plexus reconstruction What I have learned from Dr. Ezaki This is an old problem 25 years ago focus was to “fix” the nerves When that did not work, the focus shifted to transferring nerves from inside and outside the plexus 15 years ago - realization that patients with NBPP still needed orthopedic care The biggest problem for most of the kids is the shoulder (Ezaki, 2013) What I have learned from Dr. Ezaki 15 years ago - really started looking at the shoulder Focus on the internal rotation contracture alone Release alone was not enough 5 years ago - began to appreciate the early changes in the shoulder joint and to identify the dislocations Better imaging and a more aggressive approach allowed early identification of the shoulder dysplasia Maximize shoulder congruency Restore external rotation (Ezaki, 2013) Surgical Interventions: Early Nerve exploration, repair, neurolysis, graft/transfer Decision around 6 months Post-op: dressing, +/- sling, cuff and collar RTC: 2-3 weeks for wound check Maintain PROM – begin gentle PROM and scar upon discharge May have decreased function, wait for return – around 18 months Surgical Interventions: Early Closed reduction + Botox Temporary muscle paralysis to tight internal rotators 3M Soft Cast Subscapularis Teres major Pectoralis major “Big Mac” space Typically 3-12 months At/after 7 months consider open reduction Post-op: cast Fiberglass RTC: 2 week cast check,Twisted 4 weeks cast removed casting tape strut Return to PROM exercises See handout on cast care Surgical Interventions: Early Open reduction Internal rotation contracture release + Latisimus transfer Typically 7months - 3 years Post-op: cast RTC: 2 week cast check, 4-6 weeks cast removed Return to PROM exercises Typically can an initiate gentle passive internal rotation Surgical Interventions: Later Humeral osteotomy Typically school age child/adolescent Post-op: sling all the time for 3 weeks, then in public for an additional 3 weeks RTC: 2 weeks – dressing removal, 6 weeks for x-ray, 1 yr hardware removal Pendulum exercises post-op day 1-6 weeks, no impact for 6 weeks See handout Other Tendon/muscle transfers Osteotomies Gracilis Flap – Case Study Initial presentation at 4 months Birth weight 9lbs 6 oz Maternal weight gain 20 lbs Clinical Exam Flicker of elbow extension Normal hand function Wrist flexion Not present External rotation Shoulder abduction Shoulder extension Elbow flexion Wrist extension Supination Diagnosis C5-6 brachial plexopathy with no evidence of upper plexus recovery at age four months Plan: wrist splint, PROM, RTC 1 month, consider exploration Case Study Continued Surgical Intervention at 6 months of age Supraclavicular exploration of right brachial plexus with neurolysis Nerve transfer Inferior branch of spinal accessory to suprascapular nerve Nerve transfer of one radial nerve branch to the axillary nerve (triceps) Plan: Soft dressings 3 weeks RTC 3 weeks Case Study Continued MRI at 1 year of age Anterior arm compartment is essentially Later tendon muscle/transfer Case Study Continued Clinic visit at 2 years 9 months Clinical Exam Not present: Abduction/adduction Shoulder flexion Shoulder external rotation Present Some internal rotation Minimal elbow flexion Elbow extension is intact Supination/pronation Wrist flexion and extension Good hand function Plan: Continue therapy 1x/week RTC in 1 year Case Study Continued Clinic visit 3 years 9 months Proposed gracilis transfer for elbow flexion Case Study Continued Surgical intervention - 3 years 10 months Right gracilis flap to the right upper extremity Plan RTC 4-6 weeks Physical Activity Limitations WBAT on R LE Cast on the right upper extremity Case Study Continued Post-op visit - 3 years 11 months Therapy program Posterior elbow flexion splint (90 degrees) – night and out of the house Cuff and collar – in home AROM – gravity eliminated elbow Supervised swimming with floaties on his upper arm Plan: RTC 4 weeks Anticipate several more months before good control of the muscle Case Study Continued Clinic visit - 4 years (2 months post-op) Gravity eliminated elbow flexion to 80 degrees Discontinue splint and cuff and collar Case Study Video Case Study Video Therapeutic Intervention: Overview Range of Motion and Strengthening Position and Sensation Splinting Modalities ADLs/IADLs, Hand Use Psychosocial Needs / Education on Diagnosis Car Seat / Transportation Needs Referrals Range of Motion and Strengthening Goals Improve passive range of motion Improve active assist range of motion Improve active range of motion Improve strength Passive Range of Motion Passive External Rotation Starting Position Forearm supinated One hand placed on posterior shoulder Elbow flexion to 90˚ or greater See handout Ages 0-18 years, primary focus ages 0-12 months Passive External Rotation/Abduction Passive Shoulder Flexion Elbow Extension PROM Scapular Humeral Stretches Horizontal ADduction Stabilize scapula against thoracic wall Move arm into horizontal aBduction Scapular Humeral Stretches ADduction Stabilize scapula against thoracic wall Move arm into aDduction Scapular Humeral Stretches ABduction Stabilize scapula against thoracic wall Move arm into aBduction Active Range of Motion AAROM/AROM Gravity eliminated + place and hold Gravity eliminated Against gravity + place and hold Against gravity See handout Ages 0-18 years, primary focus ages 0-3 years Play Based Activities -AROM Reaching magnets on fridge, bubbles, stickers on wall or body High-five Throwing Playing with a large ball Hula hoop basket ball Crawling – living room obstacle course Swimming Putting hats/necklaces on overhead Etc – see home programs and classification Ages 0-18 years, primary focus ages 0-3 years Strengthening Scapular Stabilization – Young Child Swinging Pushing: A stroller/shopping cart Wall push ups Pulling: Tug of war Rope and scooter board Weight bearing Once approved See handout www.shallowcliffe.com www.america.gov www.photodoto.com Ages 0-6 years, or older if activities are more engaging Scapular Stabilization – Older Child Scapular Stabilization Scapular Strengthening See handout Ages 7-18 years Scapular Stabilization HEP Video Progression of Exercises PROM AROM/AAROM gravity eliminated +/- place and hold AROM/AAROM against gravity +/- place and hold AROM full range against gravity Strengthening Positioning and Sensation Goals Protect arm: Infant/Toddler decreased movement Decrease risk of shoulder dislocation Sensory awareness: Infant/Toddler decreased sensation Protect fingers: Finger Biting Decrease pain: Child/Teen with pain/limb length difference Improve fit of clothing Protect UE/safety: Awareness of decreased sensation Edema control: Positioning after surgery Positioning: Protect Arm Initial positioning for flail arm Safety Pin Pillows or towel rolls Car seat Carrier Swing See handout Ages 0-6 months, primary focus ages 0-1 month Positioning Decrease Risk of Shoulder Dislocation No weight-bearing until the shoulder joint is stable Internal rotation in weight-bearing pushes the humeral head posterior Modified Tummy Time Prone positioning No forced weight-bearing through the involved upper extremity Child will initiate weight bearing Modified “tummy time” Over parent’s lap Parent’s chest Pillow – Boppy pillow, blanket roll Arm externally rotated Ages 0-12 months, or until child initiates weight bearing or cleared by MD Sensation: Sensory Awareness, Stimulation Massage the arm with lotion Massage/tapping with various textures Cotton balls Terry cloth Stuffed animal Play with objects that have a variety of textures Protect Fingers: Finger Biting Cover fingers Band-aid Mittens/gloves Finger hugger Silipos Educate parents Ages 0-4 years, or as finger biting presents Education on Decreased Sensation Semmes Weinstein results Safety with heat Promote awareness Ages: 0-18 years Decrease Pain: Limb Length Difference Education Place arm on raised surface Desk Typing Posture Ages: school age, adolescent Scapular Stabilization / Posture Improve Fit of Clothing Modify straps – girls clothing Ages: school age, adolescent Positioning: Edema Control Post-Surgical Elevation pillow Splinting Goals Positioning: Increase function Decrease pain Stabilize Rest Increase range of motion Post-operative protection Check fit/review/re-educate See handout Shoulder Maintaining full ROM, prevents contractures Muscles with returning strength will not be able to move joint if PROM is not present POSITION: • • • • Shoulder External Rotation Elbow Flexion Forearm Supination Wrist Splint used to slightly extend wrist and to assist with supination Very difficult to maintain this position!! Ages: 0-12 months Scapular Stabilization Brace Ages: school age, adolescent Cuff and Collar Ages: infant, toddler Elbow To improve elbow extension Indications > 30 degree elbow flexion contracture Materials 1/16 inch aquaplast, volar surface Strapping crosses elbow joint Wear schedule Night time Adjust every 2-4 weeks until maximum extension Combine with stretching Ages: 0-18 years, as elbow flexion contracture presents, typically school age, adolescent Forearm TAP splint to improve pronation or supination Fabrifoam NuStim Wrap Wear schedule Fabrifoam NuStim Wrap During functional activities Rolyan TAP splint Ages: 0-18 years, consider willingness of child to wear the splint and function Wrist +/- thumb Wear Schedule At night During functional activities, if improves function Time out of splint to improve strength – wrist extension Benik w-302 Benik BD-88 Ages: 0-18 years, consider willingness of child to wear splint and function Wrist and Fingers/Thumb Modalities Goals Pain management Positioning Promote active movement Skin care Scar care Heat and Cold Heat Hot pack Paraffin Cryotherapy Ice pack Ice massage Contraindicated with diminished sensation See handout Ages: school age adolescent NMES Considerations for infants and toddlers A portion of BPP babies have impaired sensation Not verbal yet No current research on the effect of e-stim with babies/kids with BPP Need to palpate at least a muscle contraction Use for a very specific need in the older child/adolescent Kinesiotape Goals Stimulate weak muscles Positioning Wear 3-5 days 24 hour rest Application Make sure skin is clean Avoid heat/hot packs Skin test “Paper-off” tension is 10-15% Origin to insertion (proximal to distal) to stimulate contraction Muscle tissue on stretch Removal Baby oil Mineral oil (Kase, Martin, & Yasukawa, 2006) Ages: 0-18 years External Rotation Starting Position: Internal rotation ABduction Elbow flexion “I” shape Anchor: Anterior, medial epicondyle No tension Middle: Anterior humerus, posterior deltoid Paper-off tension Move into external rotation End: Spine of scapula toward spine No tension (Kase, Martin, & Yasukawa, 2006) Rhomboids Starting Position: Internal rotation, horizontal abduction, shoulder depressed and protracted “X” shape Anchor: Between spine and medial border of scapula, over Rhomboids – at an angle No tension Middle: Apply tails at an angle, medial portion higher Minimal to moderate tension (15- 50%) End: No tension (Kase, Martin, & Yasukawa, 2006) Forward Shoulder Starting Position: Shoulder girdle in alignment “Y” shape Anchor: Coracoid process No tension Middle: Angle tape in the direction for correction to occur Paper-off tension Downward pressure End: Inferior angle of the scapula No tension (Kase, Martin, & Yasukawa, 2006) Other Scapular stabilization Supination Pronation Wrist extension Skin Care / Scar Care: Post Surgical Skin Care Wash 3 times per day – mild soapy water Pat Dry Lotion (non-perfumed) or Vaseline Until skin returns to normal Scar Care “Make friends” with your scar Scar massage – several times per day Avoid sun / use sunscreen Scar pad if needed See handout ADLs, IADLs, & Hand Use Goals Increase independence ADLs IADLs School Bilateral Hand Use Assistive Devices – Dressing/Toileting Shoe buttons, elastic shoe laces Button hook Zipper pull One handed shoe tying Clothing adaptation (loops/fasteners) See handout One Handed Shoe Tying Video Assistive Devices - Bathing Long handle sponge Long handle hair washer Automatic soap dispensers for shampoo, conditioner, body wash Long handle razor Assistive Devices - Grooming Long handle hair brush Hair dryer stand One handed pony tail Toothpaste holder One hand nail clipper http://compartmentseventy6.co.uk/blog/ Assistive Devices - Eating Rocker knife Pizza cutter Built up handle School One handed typing See handout Table top scissors Clipboard to stabilize paper PE restrictions no weight bearing on upper extremity no push-ups/pull-ups allow to stop with fatigue or pain modify or eliminate impact activities Accommodations - 504 IADLs Pets Chores Meal Prep One handed cutting board Pots and Pans Suction/sticky bowls Dycem Driving North Coast Functional Solutions Bimanual Hand Use: Goals Based on AHA General Usage Arm Use Grasp and Release Fine Motor Adjustment Coordination Pace Bimanual Hand Use Consider motivation Developmental level Purpose of activity Modified Constraint See Handout Royal Children's handouts Encouraging the use of two hands Babies Toddlers Preschool School Age http://www.rch.org.au/ot/infosh eet/ Psychosocial Needs & Education on Diagnosis Goals To address: Bullying / Teasing Expressing Self/ Feelings Education on diagnosis Car Seat / Transportation Needs Hippo Car Seat Referrals Goals To address Bullying / Teasing Behavioral Concerns Community Based Therapy School Based Therapy Participation in community activities/sports Dietary concerns Orthotic needs Driving Future needs for school/work other Referral Sources Child Life Therapeutic Recreation Psychology School/ECI Outpatient/Home Health Family Services / Resource Center / Social Worker Orthotics Dietitian DARS / Texas Rehab Commission Other Home Programs Therapeutic activities the child performs with parental assistance in the home environment with the goal of achieving desired health outcomes Cerebral Palsy Institute, Darlinghurst, Sydney, Australia Pilot Study Patient population 20 patients with CP, ages 2-7 years Methods 1st visit – 1.5 hours: goal setting, creating the home program 2nd visit at 1 month – 45 min: support/follow-up 3rd visit at 3 months – 45 min: support/follow-up 4th visit at 6 months – 45 min: reassessment Participation Parent log to report participation – no specific time set by therapist 27 times per month Average daily session was 14.22 minutes Results GAS – pre: 29.86; post 50.12 (significant) PEDI – pre 44.15; post 52.1 (significant) QUEST – pre 33.83; post 39.81 (significant) (Novak, 2007) Randomized Controlled Trial Patient population 36 patients with CP ages 4-12 3 groups (no HP, 4 wk HP, 8 wk HP) Methods Same methods as pilot study Participation Parent log to report participation – no specific time set by therapist 17.5 times per month 16.5 minutes per session Results COPM and GAS – clinically significant differences for HP groups QUEST – significant changes at 8wks (not at 4wks) CAPE – no changes (Novak, 2009) Elements of a Home Program 1. Establishing collaborative relationships between parents and therapist 2. Setting mutually agreed-upon family and child goals 3. Selecting therapeutic activities that focus on goals supported by best available evidence 4. Supporting parents through education, home visits and progress updates 5. Evaluating outcomes (Novak, 2011) Step 1: Establishing collaborative relationships Therapist Role “technical expert” supports / encourages enhances care-giving competency Parent Role expert caregiver – determines what is best chooses preferred level of involvement Step 2: Setting mutually agreed-upon goals 1. What is the most enjoyable thing about _____? 2. What is _____’s best skill? 3. Who are the most important people in _____’s life? Do any of these people help _____ make changes? 4. What do you think is the most difficult thing about parenting _____? 5. What skill do you think _____ will acquire next ? 6. How does your family spend a typical day? Step 3: Setting up Therapeutic Activities Embedded into everyday routines or create new routines Parents drew from a “library of ideas” Structured practice tasks Environmental adaptations Parent education Format Written down with pictures 2 goals were realistic An hour a week does the job 4, 15 min sessions Step 4: Supporting parents through education, home visits and progress updates Instruction to the family on how to identify improvements in their child Watching the parent perform the therapeutic activities and provide feedback Identifying and relaying the child's improvements to the parent Positive reinforcement to parent to build confidence Therapist communicates interest and concern for the family Step 5: Evaluating outcomes Repeat outcome measures See handouts of examples of possible home programs Problem Therapy intervention has frequently been referred to as a “black box” due to the lack of literature that describes its specific components Ballinger, Ashburn, Low, & Roderick, 1999; Bode, Heinemann, Semik, & Mallinson, 2004; Conroy, Hatfield, & Nichols, 2005; Dejong et al., 2004; Dejong, Horn, Gassaway, Slavin, & Dijkers, 2004; DeJong, Horn, Conroy, Nichols, & Healton, 2005 Minimal evidence supporting the efficiency or effectiveness of current practice and has created variations in the cost and quality of therapy services between clinicians and geographic regions Horn, DeJong, Ryser, Veazie, & Teraoka, 2005 Decreased reimbursement or denial of therapy services by insurance companies Addressing the Problem Need to disassemble the “black box” by creating classifications that bring order and rigor to the description of therapy intervention Dejong et al., 2004 Common nomenclature to describe elements of therapy intervention and mechanisms to quantify therapy intervention Therapists clearly communicate about the interventions Researchers assess the effectiveness of the therapy process Ultimately, the development of therapy classifications will allow therapists to identify the most cost effective and efficient therapy that produces the best outcomes Current Classifications Post Stroke Rehabilitation Outcomes Project (PSROP) SCI Rehab Project Joint replacement Outcomes in Inpatient rehabilitation facilities and Nursing Treatment Sites (JOINTS) Occupational Therapy Taxomony of Rehabilitation Intervention (OT-TRI) Practice Based Evidence Methods 7 step process Form of observational & participatory action research Examines what happens in the care process e.g., Whitneck, Gassaway, Djikers, & Jha, 2009; Gassaway et al., 205, Horn & Gassaway, 2007 226 PBE 7 Step Process 1. establish a multisite, transdisciplinary clinical practice team to 1a. define key patient characteristics presumed to affect outcomes and/or effectiveness of therapies 1b. identify and define individual components of each discipline’s care process 1c. create discipline specific documentation tools 1d. incorporate documentation into routine facility practices 2. use the Comprehensive Severity Index (CSI) to control for differences in patient severity of illness 3. implement an intensive data collection protocol that captures data on patient characteristics, care processes, and outcomes 4. create a study database suitable for statistical analyses 5. successively test hypotheses based on questions that motivated the study originally 6. implement and evaluate findings from step 5 to determine whether the new or modified interventions replicate results identified in earlier phases 7. incorporate validated study findings into standard practice of care (Horn & Gassaway, 2007) 227 Three Core Elements Comprehensive information on: Patient characteristics Processes of care Multiple outcomes Product: NBPP Taxonomy-Driven Classification Patient Characteristics Assessment Types of Imaging Evaluation Guidelines Intervention Surgical Therapy 229 Patient Characteristics Demographic Information patient name patient medical record number date of birth gender ethnicity age at presentation to clinic age at final follow up Medical History Family History diagnosis (BPP) Narakas level other diagnoses history of prior/current medical care of patient history of prior/current therapy intervention type of delivery length of labor number of weeks gestation G P Ab maternal age mother's ethnicity apgar scores mother’s level of education NICU income level birth weight family support members birth length % of head circumference use of forceps/vacuum/extractions clavicle/humerus fracture history of upper extremity recovery (return of elbow flexion) mother's pregnancy weight mother's health history mother's weight gain history of gestational diabetes litigation Types of Imaging X-ray Ultrasound MRI CT other Neonatal Brachial Plexus Palsy Evaluation Guidelines Evaluations Triggered by Age Developmental and Functional Checklist (if child fails screen, standardized assessment may be utilized - Ages and Stages, Canadian Occupational Performance Measure) Pediatric Outcomes Data Collection Instrument (PODCI) (administer at ages 5/6, 10/11, 14/15 and 18 years) Evaluations Triggered by Clinical Exam Body Mass Index (BMI) (not indicated if child is in a cast or accurate height and weight cannot be taken) Passive Range of Motion (PROM) (including scapular humeral angles, selected joints depending on clinic visit) Active Movement Scale (AMS) (can be administered past the age of 5, typically AROM is used once the child is able to follow directions, AMS may not be indicated at post-operative visit) Active Range of Motion (AROM) (selected joints depending on clinical exam) Modified Mallet Classification (can be administer younger than 3 years if the child is able to reliably follow directions, may not be indicated at postoperative visit) Wong-Baker FACES Pain Rating Scale Semmes Weinstein (as indicated by clinical exam) Stereognosis (as indicated by clinical exam) Grip and Pinch (as indicated by clinic al exam) Evaluations Triggered by Open Surgical Intervention Assisting Hand Assessment (AHA) 18 yrs 17 yrs 16 yrs 15 yrs 14 yrs 13 yrs 12 yrs 11 yrs 10 yrs 9 yrs 8 yrs 7 yrs 6 yrs 5 yrs 4 yrs 3 yrs 2 yrs 19-24 mo 13-18 mo 7-12 mo 0-6 mo Canadian Occupational Performance Measure (COPM) Surgical Intervention Surgical Procedure/Intervention closed reduction closed reduction plus Botox open reduction latisimus transfers with IR contracture release internal rotation contracture release humeral osteotomy tendon transfers nerve exploration nerve grafting osteotomies - other other Therapy Intervention Categories Overall Session Information Overall Patient & Family Response Home Programs: Range of Motion & Strength Positioning & Strength Modalities Splinting ADLs and Hand Use Psychosocial & Education on Diagnosis Education on Transportation & Car Seats Referrals See handouts Breakout Session Discuss intervention strategies Review and revise NBPP classification for community based therapy Intervention: Discussion, Question & Answer Acknowledgements Texas Scottish Rite Hospital for Children Marybeth Ezaki, M.D. Scott Oishi, M.D. Janith Mills, P.A. 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Retrieved from http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf Yasukawa, A., & Cassar, M. (2009). Children with elbow extension forearm rotation limitation: Functional outcomes using the forearm rotation elbow orthosis. Journal of Prosthetics & Orthotics (JPO), 21(3), 160-166. Thank you! Contact Information Angela Shierk, OTR, PhD [email protected] TSRHC OT Department (214) 559-7786
