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.

ADHESIVE CAPSULITIS

Often called a stiff or “frozen shoulder,” adhesive capsulitis occurs in about 2% to 5% of the general population. It affects women more than men and typically occurs in people who are over the age of 45. Of the people who have had adhesive capsulitis in one shoulder, 20% to 30% will get it in the other shoulder.

What is Frozen Shoulder (Adhesive Capsulitis)?

Adhesive capsulitis is the stiffening of the shoulder due to scar tissue, which results in painful movement and loss of motion. The actual cause of adhesive capsulitis is a matter for debate. Some believe it is caused by inflammation, such as when the lining of a joint becomes inflamed (synovitis), or by autoimmune reactions, where the body launches an "attack" against its own substances and tissues. Other possible causes include:

• Reactions after an injury or surgery
• Pain from other conditions—such as arthritis, a rotator cuff tear, bursitis, or tendinitis—that has caused you to stop moving your shoulder
• Immobilization of your arm, such as in a sling, after surgery or fracture

Often, however, there is no known reason why adhesive capsulitis starts.

How Does it Feel?

Most people with adhesive capsulitis have worsening pain and then a loss of range of movement. Adhesive capsulitis can be broken down into 4 stages, and your physical therapist can help determine what stage you are in:

Stage 1 - "Pre-Freezing"

During this stage, it may be difficult to identify your problem as adhesive capsulitis. You've had symptoms for 1 to 3 months, and they're getting worse. There is pain with active movement and passive motion (movements that a physical therapist does for you). The shoulder usually aches when you're not using it, but pain increases and becomes "sharp" with movement. You'll have a mild reduction in motion during this period, and you'll protect the shoulder by using it less. The movement loss is most noticeable in "external rotation" (this is when you rotate your arm away from your body), but you might start to lose motion when you raise your arm (called "flexion and abduction")or reach behind your back (called "internal rotation"). You'll have pain during the day and at night.

Stage 2 – "Freezing"

By this stage, you've had symptoms for 3 to 9 months, most likely with a progressive loss of shoulder movement and an increase in pain (especially at night). The shoulder still has some range of movement, but this is limited by both pain and stiffness.

Stage 3 – "Frozen"

Your symptoms have persisted for 9 to 14 months, and you have greatly decreased range of shoulder movement. During the early part of this stage, there is still a substantial amount of pain. Toward the end of this stage, however, pain decreases, with the pain usually occurring only when you move your shoulder as far you can move it.

Stage 4 – "Thawing"

You've had symptoms for 12 to 15 months, and there is a big decrease in pain, especially at night. You still have a limited range of movement, but your ability to complete your daily activities involving overhead motion is improving at a rapid rate.

How Is It Diagnosed?

Often, physical therapists don't see patients with adhesive capsulitis until well into the freezing phase or early in the frozen phase. Your physical therapist will perform a thorough evaluation, including an extensive health history, to rule out other diagnoses. Your therapist will look for a specific pattern in your decreased range of motion; it's called a "capsular pattern" and is typical with adhesive capsulitis. In addition, your therapist will consider other conditions you might have—such as diabetes, thyroid disorders, and autoimmune disorders—that are associated with adhesive capsulitis.

How Can a Physical Therapist Help?

Your physical therapist's overall goal is to restore your movement so that you can perform your activities and life roles. Once the evaluation process has identified the stage of your condition, your therapist will create an exercise program tailored to your needs. Exercise has been found to be most effective for those who are in stage 2 or higher.

Stages 1 and 2

Your physical therapist will help you maintain as much range of motion as possible and will help reduce the pain. Your therapist may use a combination of stretching and manual therapy techniques to increase your range of motion. The therapist also may decide to use treatments such as heat and ice to help relax the muscles prior to other forms of treatment. The therapist will give you a home exercise program designed to help reduce the loss of motion.

Stage 3

The focus of treatment will be on the return of motion, with your therapist using more aggressive stretching and manual therapy techniques. You may begin some strengthening exercises as well, and your home exercise program will change to include these exercises.

Stage 4

In the final stage, your therapist will focus on the return of "normal" shoulder body mechanics and your return to normal, everyday, pain-free activities. The therapist will continue to use stretching, strength training, and a variety of manual therapy techniques.

Sometimes, conservative care cannot reduce the pain. If this happens to you, your physical therapist may refer you for an injection of anti-inflammatory and pain-relieving medication into the joint space. Research has shown that although these injections don’t provide longer-term benefit for range of motion and don’t shorten the duration of the condition, they do offer short-term benefit in reducing pain.

Can this Injury or Condition be Prevented?

The cause of adhesive capsulitis is debatable, with no definitive cause, so there is no known method of prevention. The onset is usually gradual, with the disease process needing to "run its course."

Real Life Experiences

Cheryl L. is 47-year-old woman whose physical therapist has diagnosed her with adhesive capsulitis. She has no history of trauma and reports a slow onset of pain that increased over the past 6 months. She says that it significantly affects her sleep.

Her pain is accompanied by a loss of range of movement that has now progressed to the point where she can’t lift her arm to shoulder level. Her therapist provides heat treatments to relax her muscles and designs a home exercise program to help stall the loss of motion. He monitors Cheryl periodically, encouraging her to continue with the home exercises despite the pain. Treatment in the physical therapy clinic consists of stretches performed by the therapist, who also mobilizes the joint to help maintain its current range of motion. At this stage, the therapist focuses the manual therapy not on increasing range of motion but on mobilizing the joint to reduce pain and reduce the amount of range of motion that is lost.

When Cheryl progresses into stage 3 ("frozen"), her visits to the physical therapist are increased. The therapist uses stretching and manual therapy techniques to improve her range of motion. After 4 weeks of treatment, Cheryl reports minimal pain, and her range of motion is beginning to increase rapidly. Her therapy is reduced to weekly visits and then to twice monthly visits. Fourteen months after the onset of her condition, her range of motion returns to normal, and her pain has stopped. Cheryl's progress is rapid, and the therapist credits this to her full participation in her exercise program.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat people who have frozen shoulder, or adhesive capsulitis. You may want to consider:

• A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems.
• A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopaedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

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:

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with frozen shoulder.
• During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.