BRACHIAL PLEXUS PALSY

A brachial plexus palsy happens when the nerves of the brachial plexus have been damaged during birth. The brachial plexus is a set of nerves that control the muscles of the arm. Palsy means not being able to move muscles in an area (paralysis).

Nerves are soft, tube-like structures inside the body. They contain many small fibers (filaments), like a telephone cable or a thick electrical cord. These small fibers carry signals from the brain to control the muscles. Nerves also carry signals from the skin to the brain. This is how we feel things on our skin.

The nerves of the brachial plexus go out from the spinal cord under the collarbone and into the armpit. From there, they branch out into individual nerves that control the muscles in the shoulder, elbow, wrist and hand.

When nerves in the brachial plexus get damaged, signals cannot travel like usual from the brain to the arm muscles. So some or all of your child’s arm muscles may no longer work. When this affects only the shoulder and elbow muscles, it is called an Erb’s palsy. When it affects all of the muscles of the arm, hand and wrist, this is known as a total plexus palsy.

Brachial Plexus Palsy in Children

Brachial plexus palsies usually happen because of a stretch injury to your child’s head, neck and shoulder. This can happen during birth, especially when the birth is difficult or complex. Sometimes a child’s shoulder will get stuck against the mother’s pelvis. This can result in a stretch injury as your child is being delivered.

The brachial plexus may be injured if a baby's shoulder gets stuck on the mother's pelvis during birth.

In older children, a brachial plexus palsy can occur because of an injury where the neck and shoulder get stretched.

Many children with a brachial plexus palsy recover on their own. But if the condition does not completely resolve within 1 month, it usually has lasting effects. That’s why we encourage you to have your child assessed 1 month after their birth or injury if they have not fully recovered. If treatment is needed, it’s important to begin early and to have ongoing therapy.

Physical and occupational therapy can reduce problems with stiffness or other bone problems that can happen as a result of the injury. Some children need to wear splints to help position their joints while the nerves are recovering. Some need surgery to repair their nerves.

DOWN SYNDROME: LEARN MORE ABOUT THE ROLE OF PHYSICAL THERAPY

Down syndrome (DS) affects approximately 6,000 (1 in 700) babies born in the United States (US) each year. Most children with Down syndrome experience physical and developmental delays, and may have physical conditions requiring treatment. Individuals with Down syndrome experience cognitive (intellectual) delays, but the effect is usually mild to moderate and is not indicative of the many strengths that each individual possesses. Approximately 400,000 people living in the US and more than 6 million people worldwide have Down syndrome. Physical therapists work with individuals with Down syndrome from infancy through adulthood to help them function at their maximum potential and lead healthy, productive lives.

What is Down Syndrome?

Down syndrome, also called Trisomy 21, is a genetic disorder causing babies to be born with an extra copy of chromosome 21. Chromosomes determine how a baby grows in the mother's womb before birth and how the baby's body functions after birth; normally, a baby is born with 46 chromosomes. The extra copy of chromosome 21 in babies born with Down syndrome changes the typical development of the brain and the body, causing intellectual and physical challenges.

The current average life span of a person with Down syndrome living in the US and in other developed countries is approximately 60 years. Although DS continues throughout a person's life span, children and adults can improve their ability to perform movement activities and everyday tasks with the help of physical therapists and other health care professionals. Physical therapists working side-by-side with individuals with Down syndrome and their families can help prevent some of the complications of DS, such as developmental delay and obesity, and help boost and maintain their levels of heart and cardiovascular fitness.

Signs and Symptoms

Down syndrome may be detected during pregnancy by screening or diagnostic tests. If not detected before birth, Down syndrome usually is detectable at birth by the baby's physical characteristics. These physical characteristics include:

• Low muscle tone
• A single deep crease across the palm of the hand
• A slightly flattened facial profile, and an upward slant to the eyes

A chromosomal analysis of a newborn baby can be performed to confirm a diagnosis of DS.

Approximately 40% to 60% of babies born with DS will have some type of congenital heart disease, which may be noted at the time of birth or soon following birth. Motor development (movement) is often delayed because the baby may have low muscle tone, decreased strength, increased movement at the joints, postural and balance difficulties, feeding problems, or challenges with hand use. Children with Down syndrome also may experience some vision and hearing challenges, and develop and use language at a slower rate. They also often require increased time to learn complex movements, such as riding a tricycle.

Other challenges may include:

• Poor language development and use
• Vision and hearing problems
• Cognitive (ie, thinking, decision making) difficulties
• Obesity

In later childhood and adulthood, people with DS may develop other challenges, such as:

• Difficulty learning complex movement tasks
• Degenerative joint disease
• Poor cardiovascular health (ie, hypertension)
• Thyroid dysfunction
• Diabetes
• Skin disorders
• Lower bone density
• Digestive problems
• Leukemia
• Sleep apnea
• Depression (approximately 30% of cases)
• Early onset of dementia

Physical therapists will work with the individual, the family, and other health care providers to reduce the effect of these conditions, or even prevent them from developing.

Good medical care, strong educational environments that include physical therapy from preschool through high school and into adulthood, and support from families can help keep adults with DS living at their maximum potential. Many adolescents and adults with DS participate in family and community activities and lead happy, productive lives.

How Is It Diagnosed?

Three types of DS have been identified, and all types are diagnosed by a chromosomal analysis—frequently a blood test—ordered by a physician.

Type 1. The most common type of DS is called "Nondisjunction Trisomy 21." This type of DS occurs when 3 copies of chromosome 21 are present in the fertilized egg. Typically, 1 copy of chromosome 21 comes from the father and 1 copy comes from the mother. When 3 copies are present, the extra chromosome may come from either the mother or the father. As the baby develops, the extra chromosome is copied into every cell in the body.

Type 2. Translocation Trisomy 21 is seen in about 4% of all people with Down syndrome. In this type of DS, part of chromosome 21 breaks off during cell division of the fertilized egg and attaches to another chromosome. The total number of chromosomes in the cells is the usual 46, but the extra part of chromosome 21 causes the baby to have the characteristics of Down syndrome.

Type 3. Mosaic Trisomy 21 occurs in approximately 1% of persons with Down syndrome. This type of DS develops when a "nondisjunction" or error occurs in 1 of the cell divisions of the fertilized egg, but not all cell divisions are affected. Some of the baby's cells contain 46 chromosomes, which is typical, but other cells contain the extra chromosome 21 for a total of 47. People with Mosiac DS may have fewer characteristics of the syndrome.

How Can a Physical Therapist Help?

The physical therapist is an important partner in health care and fitness for anyone diagnosed with DS. Physical therapists help people with DS gain strength and movement skills in order to function at their best throughout all the stages of life.

Specifically, physical therapists work with children with DS to improve muscle strength, balance, coordination, and movement skills to improve independence with daily activities and quality of life. Early intervention by a physical therapist helps a child with DS develop to their maximum potential.

Your child's physical therapist will perform an evaluation that includes:

• Birth and developmental history. Your physical therapist will ask questions about your child's birth and developmental stages (the age he or she performed activities such as holding the head upright, rolling over, sitting up, crawling, walking, and running).
• General health questions. Your physical therapist may ask some of the following questions: Has your child been sick or hospitalized? When did your child last visit a physician or health care provider? Were any health concerns shared with you during that visit? Has your child had any surgeries?
• Parental concerns. Your physical therapist will ask about your chief concerns. What are your goals? What do you hope to accomplish first in physical therapy?
• Physical examination. The physical exam may include measuring your child's height and weight, observing movement patterns, and making a hands-on assessment of his or her muscle strength and tone, movement, flexibility, posture, balance, and coordination. Your child’s heart health and fitness may also be assessed, as well as his or her foot posture and potential need for orthotics.
• Motor skill acquisition. Your physical therapist will perform specific tests to determine your child's motor development such as sitting, crawling, kneeling, pulling up from sitting to standing, walking, and more advanced skills like running, jumping, or kicking and throwing a ball. Your therapist also may screen the child's hand use, vision, learning strategies, and other areas of development.
• Referrals. Your physical therapist may refer you to other health care professionals who can participate in a team effort to address your child's needs. The therapist may coordinate regularly with other consultants, such as a developmental pediatrician, a cardiologist, or a speech and language therapist, to schedule regular checkups.

The physical therapist will design an individualized treatment program that may include:

• Improving strength. Your physical therapist may teach you and your child exercises to increase muscle strength. The therapist will identify games and fun tasks that improve strength, and adjust them as the child grows, identifying new fitness activities to reduce the risk of obesity and increase and maintain heart health.
• Improving developmental skills. Your physical therapist will help your child learn to master motor skills such as crawling, pulling up from sitting to standing, and walking. Research has shown that infants with DS can benefit from activities like walking on a treadmill. Physical therapists can help caregivers support their child's movement development by providing hands-on training for positioning, movement, feeding, and play. Your physical therapist also may suggest changes at home to encourage movement development, communication, hearing, vision, and play skills.
• Improving balance, coordination, and postural control. Your physical therapist may use equipment such as a firm, round pillow or an exercise ball to improve your child's ability to hold the head erect or to maintain a sitting position. Other skills such as jumping, skipping, and dribbling a ball may be incorporated into a fun physical therapy regimen.
• Improving physical fitness. Your physical therapist will help determine the specific exercises, diet, and community involvement that can promote healthy living choices for your child, and prevent complications of DS, such as activity limitations and decreased participation with siblings or peers.

Physical therapy may be provided in the home or at another location like a community center, school, or a physical therapy outpatient clinic. Physical therapists work with other health care professionals to address the needs of individuals with DS, as treatment priorities shift throughout their lifespans.

How Often Does This Occur?

The exact cause of the chromosomal changes that result in DS is not known, but the disorder is associated with increasing age in mothers. Women older than 35 years at the time of childbirth have an increased incidence of having a baby with Down syndrome. Mothers at age 20 have an incidence of having a baby with DS at 1 in 2,000 births; at age 40, incidence increases to 1 in every 100 births. However, due to the fact that younger women have a much greater childbirth rate, the overall majority of babies with DS are born to women younger than 35 years of age.

Excellent prenatal care is important for all pregnant women. Once a child is diagnosed with DS, the physical therapist and other health care professionals can prevent or reduce additional complications that might occur following birth.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:

• A physical therapist who is experienced in pediatrics and developmental disorders. Some physical therapists have a pediatric practice and will work with you and your child in the clinic, home, school, and community environment.
• A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in pediatric physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to developmental conditions such as DS.
• Experienced pediatric physical therapists who also understand the importance of working with other health care professionals as needed to maximize outcomes for people with DS.
• A physical therapist who specializes in neurological conditions, musculoskeletal impairments, or pain management for an adult with DS, depending on that individual’s needs. Your physician or physical therapist can direct you to the appropriate specialist.
• Early-intervention physical therapy from birth to 3. Each State in the US is responsible for providing early intervention programs for infants and toddlers. Services for children are provided at the local level, under state supervision. Find out the agency for your state at the ECTA Center, or contact your pediatrician or family physician.

 You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic or home health agency for an appointment, ask about the physical therapists' experience in helping children with Down syndrome or other developmental disorders.
• During your first visit with the physical therapist, be prepared to describe your child's symptoms and motor skills in as much detail as possible.
  
  For more information, visit www.apta.org

ALMOST 1/2 OF BABIES HAVE FLAT SPOTS

Putting babies to sleep on their backs is preventing sudden infant death syndrome (SIDS), but too much time on their backs it might also be leading to an increase in flat spots on babies' heads.

As reported by NBC News (Nearly half of babies have flat spots, study finds - July 8, 2013), a recent study found that 46.6% of babies had some form of plagiocephaly ("oblique head").

The solution includes varying the side of the head that is placed down when the baby goes to sleep, and also increased "tummy time." Tummy time, even when infants are still very young, is so important. Babies come out flexed up into a ball, and as their muscles begin to relax and their bodies straighten out, tummy time helps the muscles in their neck become active. Babies can typically begin to lift their heads and clear their mouth/nose as early as 10 days after they're born! Within the 1st month, they should begin to get a little bit of clearance, within the 2nd month they should be able to lift their whole head off the ground, and by the 3rd month your baby should be able to hold their heads up and support themselves on their elbows. Once your baby can support their upper body on their elbows, they're typically within ~6 months of crawling! 

Download Tummy Time Tools from the APTA's website for quick tips on how to position, carry, hold, and play with your baby to promote muscle development in the child's neck and shoulders and avoid the development of flat areas on the back of the baby's head.

INFANT BRACHIAL PLEXUS INJURIES

The brachial plexus is a network (bundle) of nerves in the shoulder and under the arm. The network is composed of the nerves that carry signals from the spinal cord to the shoulder, arm, hand, and fingers. These signals transmit information between the brain, the spinal cord, and the arm and hand and are required for typical movement and feeling (sensation). If nerves in the upper part of the brachial plexus bundle are damaged, the injury is called Erb’s (or Erb-Duchenne) Palsy. If the nerves in the lower part of the brachial plexus are damaged, the injury is called Klumpke’s (or Dejerine-Klumpke) Palsy. In some instances, all the nerves may be damaged, resulting in "global" palsy.

Injuries to the brachial plexus result in movement and sensation difficulties in the arm, which may be mild or severe, and temporary or prolonged. Brachial plexus injury occurs in approximately 1.5 of every 1,000 infants born; the rate of injury is lower in smaller infants (under 6 pounds) and increases as the size of the infant increases, especially in babies who weigh 9 pounds or more.

What is a Brachial Plexus Injury?

The brachial plexus is a bundle of nerves that runs from the neck through the shoulder to the arm. Although injury can happen anytime, most brachial plexus injuries occur during birth when the infant's shoulder becomes wedged in the birth canal. This event, called shoulder dystocia, can stretch the brachial plexus, damaging the nerves. The delivery becomes an emergency situation, and additional maneuvers are required to deliver the infant. Injury also may occur without shoulder dystocia if the labor is long, the infant is large, the mother develops gestational diabetes, the delivery requires external assistance (such as forceps), or if a breech birth (buttocks- or feet-first rather than head-first) occurs.

Possible Causes

Erb's or Klumpke's Palsies result from 4 types of brachial plexus injuries:

• Neuropraxia occurs when 1 or more of the nerves are stretched and damaged, but not torn. It is the most common type of injury to the nerves of the brachial plexus, and may heal spontaneously.
• Neuroma results from a torn nerve that heals, but scar tissue develops. The scar tissue puts pressure on the injured nerve and prevents signals from being transmitted between nerves and muscles. Neuroma injuries require treatment to heal.
• Rupture describes a torn nerve, but the tear is not at the site where the nerve attaches to the spine. Surgery will be required, and the muscles may continue to weaken if physical therapy treatment does not occur following surgery.
• Avulsion is the most severe type of injury, in which the nerve is torn from the spine. The size and growth of the arm or hand may be affected, and damage may be present for life.

Signs and Symptoms

The signs and symptoms of brachial plexus injury vary, depending upon which nerves are damaged and the extent of the damage. Major damage may result in a limp or paralyzed arm. The arm muscles are weak and lack feeling or sensation.

In Erb's Palsy, the signs may be a stiff arm that is rotated inward with the wrist fully bent and fingers extended. This position is often called the "waiter's tip" because it resembles a food server holding the hand discreetly for a tip.

If other nerves are damaged, as in Klumpke's Palsy, the posture of the arm will be different. Sometimes the fingers and hand can move even when the arm has limited movement. The amount of pain that is present also is dependent upon the extent of the nerve damage.

How Is It Diagnosed?

Brachial plexus injuries are often apparent at birth because the infant's arm is limp or unusually stiff. Diagnosis of the injury requires a careful neurological examination by a specialist to determine which nerves have been affected, and the severity of the injury. Usually, the examination will include physical observation of the arm as well as some special tests, such as an electromyogram (EMG) that reveals the extent of muscle damage caused by the nerve injury. A nerve conduction study (NCS) may be used to determine how far signals are transmitted along the nerves. Other scans may be required to assess the damage to the nerves.

Some children's hospitals offer a team approach in diagnosing and treating children with brachial plexus injuries. The specialists on the team might include physicians, orthopedic surgeons, and physical therapists. Surgery may be necessary if the nerve damage is too extensive for recovery with therapy alone. Physical therapy will likely be a part of the treatment plan, whether or not the child has surgery. Sensory re-education may be included if the brain forgets how the arm and hand should function during the time the nerve is regrowing or healing. Seeking treatment as early as possible, and seeking care by experts in brachial plexus injury can make a big difference in helping a child gain full use of their arm.

How Can a Physical Therapist Help?

A physical therapist is an important family treatment partner for any child diagnosed with a brachial plexus injury. Physical therapy should begin as soon as possible after diagnosis or surgery, and before joint or muscle tightness has developed. Physical therapists will:

• Identify muscle weakness and work with each child to keep muscles flexible and strong.
• Help reduce or prevent muscle or joint contractures (tightening) and deformities.
• Encourage movement and function.

Even when surgery is not required, therapy may need to continue for weeks and months as the nerves grow again or recover from damage. Children with Erb's Palsy will usually recover by 6 months of age, but other palsies may require longer treatment. Each treatment plan is designed to meet the child's needs using a family-centered approach to care.

Evaluation. Your child's physical therapist will perform an evaluation that includes a detailed birth and developmental history. Your child’s physical therapist will perform specific tests to determine arm function, such as getting the child to bring the hands together, grasp a toy, or use the arm for support or for crawling. The physical therapist will test arm sensation to determine whether some or all feeling has been lost, and educate the family about protecting the child from injuries when the child may not be able to feel pain. Physical therapists know the importance of addressing the child’s needs with a team approach, review all health care assessments, and send the child for further evaluation, if needed.

Treatment. Physical therapists work with children with brachial plexus injury to prevent or reduce joint contractures, maintain or improve muscle strength, adapt toys or activities to promote movement and play, and increase daily activities to encourage participation—first in the family, and later, in the community. Treatments may include:

• Education on holding, carrying, and playing with the baby. Your physical therapist will make suggestions for positioning, so that your baby's arm will not be left hanging when the baby is being held or carried. Your physical therapist will provide ideas for positioning the baby on the back or stomach for play without injury to the arm.
• Prevention of injury. Your physical therapist will explain the possible injuries that could occur without the baby crying, since the baby cannot perceive pain if sensation is limited in the arm.
• Passive and active stretching. Your physical therapist will assist you and your child in performing gentle stretches to increase joint flexibility (range of motion), and prevent or delay contractures (tightening) in the arm.
• Improving strength. Your physical therapist will teach you and your child exercises and play activities to maintain or increase arm strength. Your physical therapist will identify games and fun tasks that promote strength without asking the baby to work too hard. As your child improves and grows, your physical therapist will identify new games and activities that will continue to strengthen the arm and hand.
• Use of modalities. Your physical therapist might use a variety of intervention techniques (modalities) to improve muscle function and movement. Electrical stimulation can be applied to gently simulate the nerve signal to the muscle and keep the muscle tissue functional. Flexible tape can be applied over specific muscle areas to ease muscle contraction. Constraint-induced movement therapy (CIMT) may be applied to the nonaffected arm to encourage use of the affected arm. Repetitive training of the affected arm is encouraged, using age-appropriate tasks, such as finger painting, building a tower, or picking up and eating small bites of food. Your physical therapist will collaborate with other health professionals to recommend the best treatment techniques for your child.
• Improving developmental skills. Your physical therapist will help your child learn to master motor skills, like putting the child’s weight on the injured arm, sitting up with arm support, and crawling. Your physical therapist will provide an individualized plan of care that is appropriate based on your child’s needs.
• Fostering physical fitness. Your physical therapist will help you determine the exercises, diet, and community involvement that will promote good health throughout childhood. Your physical therapist will continue to work with you and your child to determine any adaptations that may be needed, so that your child can participate fully in family life and in society.

Therapy may be provided in the home or at another location, such as a hospital, community center, school, or a physical therapy outpatient clinic. Depending upon the severity of the brachial plexus injury, the child's needs may continue and vary greatly as the child ages. Your physical therapist will work with other health care professionals, eg, occupational therapists and physicians, to address all your child's needs as treatment priorities shift.