guide for therapists...this injury is traditionally known as erb’s palsy when c5 and c6 are...

Guide for therapists working with

NEONATAL BRACHIAL PLEXUS PALSY

This information has been created and compiled by the therapists from Neonatal Brachial Plexus Palsy Team, The Children’s Hospital at Westmead, Sydney Children’s Hospitals Network in conjunction with the Allied Health Educator, Children’s Healthcare Network. This cannot be reproduced in any form without their express permission. 2

1. Guide for therapists working with children with Neonatal Brachial Plexus Palsy 4

Introduction 4

Objectives 4

Instructions to users 4

2 Background 5

Terminology 5

Aetiology 5

Prevalence/incidence 5

Types of injury 5

Associated presentations 6

Surgical interventions 6

3 Musculoskeletal management of the shoulder 9

4 Assessment 10

Body function and structure 10

Activity and participation 10

Occupational performance 10

Environmental 10

5 The assessment process 11

History 11

Observation 11

Standardised assessments 11

6 Role of therapy with a child with NBPP 13

Model of therapeutic intervention 13

7 Intervention 15

0 – 6 months of age 16




18 months – 3 years of age 24

Preschool age (3–5 years) 26

School age (4–7 years) 29

Primary and high school age 31

8 Preparing for the future 33

Body image and cosmetic consideration 33

Pain 33

One handed Activities of Daily Living 33

Driving 33

Part-time job 34

Higher School Certificate (HSC) 34

Disability provisions in the HSC 34

Transitioning to the workplace 34

Transition to adult services 35

9 Modified Constraint Induced Movement Therapy (Mod CIMT) 36

Introduction 36

The mitt 36

Early constraint under 12 months of age 37

Constraint at 18 months of age 39

Constraint at 3 years of age or older 40

10 Other therapeutic interventions 42

Serial casting and splinting 42

Dynamic taping for scapula stabilisation 43

Neuromuscular Electrical Stimulation 43

Sup-ER orthosis 43

CONTENTS


11 References 44

Appendix One: 46

Upper Limb Spica: Information for Parents and Carers

Appendix Two: 49

Babies with NBPP: Stretching the shoulder

Appendix Three: 52

Babies with NBPP: Ways to encourage active movement of the weaker arm

Appendix Four: 57

Suggested toys for children with NBPP

Appendix Five: 60

Children with NBPP: Ways to encourage active movement of the weaker arm

Appendix Six: 65

Children with NBPP: Stretching the upper limb

Appendix Seven: 69

Children with NBPP: Ways to encourage the development of two handed (bilateral) coordination

Appendix Eight: 73

Children with NBPP: Adducted hand to mouth

Appendix Nine: 75

Children with NBPP: Encouraging active forearm supination

Appendix Ten: 78

Children with NBPP: Encouraging active forearm pronation

Appendix Eleven: 81

Children with NBPP: Encouraging active elbow extension with reaching activities

Appendix Twelve: 84

Children with NBPP: Getting ready for school

Appendix Thirteen: 86

Children with NBPP: Template of letter for preschool

Appendix Fourteen: 89

Children with NBPP: Template of letter for starting school

Appendix Fifteen: 92

Children with NBPP: Template of letter for high school

Appendix Sixteen: 95

Children with NBPP: Examples of home program and timetable for Mod CIMT


Guide for therapists working with children with Neonatal Brachial Plexus Palsy

IntroductionThe purpose of this guide is to provide resources to support occupational therapists and physiotherapists in the assessment and management of children diagnosed with Neonatal Brachial Plexus Palsy (NBPP). This guide aims to allow children with NBPP to reach their potential, achieve full participation in everyday activities and maximise their quality of life.

This guide was developed with reference to current knowledge regarding nerve injury and the recovery process on the musculoskeletal system of the developing upper limb. Evidence based practice in the management of children with NBPP should involve consideration of research literature, supported by clinical observation and expertise of the treating therapist. The content of this guide reflects the current approach to the assessment and management of children with NBPP undertaken at The Children’s Hospital at Westmead, Sydney Children’s Hospitals Network.

Objectives1. To provide recommendations that reflect what is currently recognised as best clinical practice in line with research and consensus

regarding management of children with NBPP.

2. To provide resources and contacts for therapists working with children with NBPP.

Instructions to usersThese resources are applicable to healthcare settings in metropolitan, regional, rural and remote areas of New South Wales (NSW).

As in any clinical situation and due to the heterogeneous nature of NBPP, there may be variables which cannot be covered by a single resource. This guide is one component of clinical decision-making, which takes into account clients’ preferences and values, clinicians’ values and experience, current available research and the available resources. Clinical reasoning regarding the management of clients remains paramount. Clinicians and clients need to develop individual treatment plans that are tailored to the specific needs and circumstances of the child and family.

When working with children who have NBPP, a person/family centred approach to therapy plays an integral role in supporting the individual with NBPP to realise their potential. Positive outcomes from a family centred approach recognises the need to actively listen to the individual and their family to identify, respect and value what is important to them and for them.1 It is important that there is a balance between the child’s goals, strengthening and supporting the family and their role in the child’s life.2

A family centred approach to working with children includes the following principles:

– The family deciding on their own level of involvement in decision-making. – The family having ultimate responsibility for the child’s care. – The family being treated with respect. – Consideration of the needs of all family members. – Encouragement of the involvement of all family members.

Existing research evidence, investigating the psychological adjustment of the child, psychosocial well-being of the parents and satisfaction with the service providers, although limited, all pointed to positive outcomes from the family centred service approach.3

A multidisciplinary team approach is considered best practice when working with children with complex needs.4 A multidisciplinary team approach may not be feasible in all settings due to a number of constraints. It is recommended that where possible occupational therapists and physiotherapists work together in a family centred model to meet the needs and goals of the child and their family. Therapists who do not work as part of a team are encouraged to seek support from other professionals to facilitate the provision of a holistic service.

Resources Support is available from the therapists who work with children with Neonatal Brachial Plexus Palsy within the Occupational Therapy and Physiotherapy Departments at The Children’s Hospital at Westmead, Sydney Children’s Hospitals Network. These therapists also attend the Upper Limb Clinic, a specialist multidisciplinary clinic in NSW for children with Neonatal Brachial Plexus Palsy.

For further information contact the Occupational Therapy Department or Physiotherapy Department on (02) 9845 3369.


Background

TerminologyDamage to the brachial plexus can occur at birth resulting in what is known as Obstetric, Congenital, Perinatal or Neonatal Brachial Plexus Palsy.

AetiologyNBPP occurs as a result of sustained lateral flexion stretch with traction to the cervical spine of the infant during the birth process. This may be due to a number of factors such as the baby’s size, position of the baby within the pelvis, size and shape of the mother’s pelvis and the delivery mechanism. This stretch to the cervical spine results in nerve damage to the brachial plexus leading to muscle weakness and imbalance to the developing affected upper limb.

There is evidence to suggest that shoulder dystocia increases the risk for NBPP.5 Shoulder dystocia occurs when the shoulder of the baby becomes stuck at the time of delivery under the the pubic symphysis, opening the angle between the clavicle and cervical spine, and creating an upward tension gradient.6

Brachial Plexus7

Prevalence/incidence The incidence of NBPP is 1–2 per 1000 births.7 Prognosis for these children is variable depending on the severity of the injury and subsequent management.7 At least 75 per cent of infants have full spontaneous recovery within weeks or a few months. Return of anti-gravity biceps by three months is a good prognostic indication (often used for surgical decisions).8 The remaining 25 per cent of infants will have varying degrees of permanent neurological damage resulting in muscle weaknesses, imbalances and secondary musculoskeletal changes to the upper limb.

Types of injury The types of injury that can occur to the Brachial Plexus range from a neuropraxia (stretching of the nerve), axonotmesis, neurotmesis through to a complete avulsion of the nerve root from the cervical spine.9 Neuropraxia is likely to fully recover in a short time frame. Total avulsion of the nerve root, however, results in no anticipated recovery to the upper limb. In between these two extremes the actual nerve injury can be difficult to fully determine.

Left brachial plexus7

The location of the injury will impact on the functional presentation of the child.

– Upper plexus (C5, C6 and C7) the shoulder is most affected. This injury is traditionally known as Erb’s Palsy when C5 and C6 are involved.


– Lower plexus (C8, T1) the hand is more affected which is a less typical type of injury. Traditionally this injury is referred to as Klumpke’s Palsy.

– Pan Plexus (C5, C6, C7, C8 and T1) the entire plexus is affected resulting in shoulder, elbow, forearm, wrist and hand involvement.

Although children have some recovery during the first years of life, they can be left with ongoing weakness of specific muscles around the shoulder, elbow, forearm and hand.

Associated presentations Associated presentation may include:

Horner’s SyndromeHorner’s syndrome consists of a droopy eyelid and constricted pupil on the side of the brachial plexus injury. It reflects injury to the sympathetic nerve at the C8-T1 level.

Phrenic Nerve InjuryInjury to C3-C5 can affect the phrenic nerve which controls the diaphragm. Respiration is affected by breathing difficulty, asymmetrical chest movement and increased risk of chest infection.

Surgical interventions A small percentage of children with a non-resolving brachial plexus palsy will require surgical intervention to improve functional outcomes. The following table provides a brief overview, these interventions are dependent on the surgeons involved.


Table 1: Surgical Interventions

Intervention Procedure Post operative care

Nerve graft surgery

4–6 months of age

Surgical exploration to establish the extent of the avulsed nerve roots.

Removal of scar tissue (neurolysis).

Perform nerve repair (or neurotisation).

NB: This surgery is documented in the literature although at present this is not a surgical procedure routinely performed at The Children’s Hospital at Westmead.

Post operative – Initially immobilised with arm across chest for four weeks. – Active movement encouraged once strapping or sling removed. – Passive stretches recommence when directed by the surgeon usually after immobilisation period.

– Follow up two weeks later at clinic. – Scar management for neck and donor site (normally calf muscle area).

Recovery – Regenerating axons grow approximately 1mm per day. 10cm nerve segment may take approximately three–four months.

– Recovery should be expected to continue for 12–18 months post operatively.

– Goal of therapy is to maintain the muscle range and joint movement until reinnervation occurs.

– Targeted active movement/strengthening of identified weak muscles typically shoulder external rotators/abductors, elbow flexion/extension, forearm supination and wrist extensors.

Nerve transfer surgery

12–15 months of age

Commonly spinal accessory nerve transferred to suprascapular nerve.

Can be combined with Botox and shoulder spica if there is restriction in passive range of movement to shoulder external rotation.

Post operativeEither:

– Collar and cuff for two weeks; or – Arm taped across chest in similar position to collar and cuff for two–three weeks.

After removal of sling or tape child can resume active movement of arm in controlled setting.

– Passive range of motion exercises are re-established at this time.

1. External rotation of the shoulder2. Elbow extension and supination/pronation of the forearm.

– Active movement and use of the affected upper limb targeting external rotation.

– Modified constraint induced movement therapy may be appropriate at this time.

Shoulder rebalancing surgery

18 months–3 years

Transfer of latissimus dorsi to infraspinatus.

May involve release of associated muscles such as subscapularis and pectoralis major and coracohumeral ligament.

Post operative – Shoulder spica cast for six weeks. – Car seat may need modifying for shoulder spica. – Upper body clothes will need alteration, for example Velcro openings along side seams.

Therapy management following removal of shoulder spica:

– Passive range of motion exercises are re-established at this time.

1. External rotation of the shoulder 2. Elbow extension and supination/pronation of the forearm.

– Active movement and strengthening of shoulder external rotators/abductors and elbow extension.

– Modified constraint induced movement therapy (Mod CIMT) to re-establish use of the affected upper limb should be considered.

– Restriction of outdoor activities including playground, trampoline and bikes for a further 3–4 weeks.


Intervention Procedure Post operative care

Other orthopaedic surgery

8–15 years

Upperarm – Derotational humeral osteotomy

Post operative – Specific instructions will be provided by the orthopaedic team post operatively.

Elbow/Forearm – Interosseous release – Tendon transfer

Post operative – Specific instructions will be provided to the treating therapist by the orthopaedic team post operatively.

Hand – Tendon transfers – Wrist fusion

Post operative – Specific instructions will be provided to the treating therapist by the orthopaedic team post operatively.

Resources

Appendix 1: Travelling in a modified child restraint Children who have had certain orthopaedic procedures may require a specific type of cast for positioning during recovery. Shoulder spicas may require modification to car seat and stroller.

Hand Surgery Specialist SurgeonThis website by Dr Nicholas Smith, internationally recognised othopaedic upper limb surgeon provides useful background in regard to surgery options and procedures.

https://www.drnicholassmith.com.au/hands/neonatal-brachial-plexus-injuries/.

Ongoing support and referralSupport is available from the therapists who work with children with Neonatal Brachial Plexus Palsy within the Occupational Therapy and Physiotherapy Departments at The Children’s Hospital at Westmead, Sydney Children’s Hospitals Network. These therapists also attend the Upper Limb Clinic, a specialist multidisciplinary clinic in NSW for children with Neonatal Brachial Plexus Palsy.



Musculoskeletal management of the shoulderShoulder dysfunction is the most common long-term complication of neonatal brachial plexus injuries. It has been reported that approximately 10 per cent of children with a non-resolving brachial plexus injury develop glenohumeral dysplasia.10 Magnetic Resonance Imaging (MRI) changes relating to the appearance of the glenoid and the position of the humerus have been reported in children as young as two months of age.11

These changes are progressive and are secondary to muscle imbalance. Weakness of infraspinatus, altered biomechanics and muscle degeneration of the subscapularis muscle12 and the unopposed action of pectoralis major and latissimus dorsi are contributing factors towards the development of an internal rotation contracture of the shoulder. Bony changes that can occur to the glenohumeral joint are loss of subacromial space, acromial beaking, changes in glenoid shape to either flat, biconcave or pseudoglenoid and concurrent change in humeral head shape.12, 13

The resultant coupling of muscle imbalance and glenohumeral dysplasia can lead to posterior shoulder dislocation. A loss of passive external rotation of the shoulder is an indication of posterior dislocation.10 Consistent monitoring of the shoulder on a regular basis will alert the physiotherapist to any changes around the shoulder joint.

Other clinical signs such as posterior fullness caused by displacement of the humeral head, apparent shortening of the humerus and asymmetrical skin folds are also indicative of a posterior shoulder dislocation.10

The interventions that physiotherapists employ with infants and children involve maintaining or regaining full passive external rotation of the shoulder. For this to occur documentation of the passive and active external rotation range of motion is essential at each visit. When performing passive shoulder external rotation it is essential to stabilise the scapula by placing the child in supine, maintain the humerus in adduction against the thorax whilst externally rotating the shoulder.

Parents are advised to perform the external rotation stretch (that is a stretch into full passive shoulder external rotation) with each nappy change holding each stretch for 20–30 seconds and repeating 5–10 times. For most infants/children this is easy to achieve and there is no loss of passive shoulder external rotation.

However, in a small number of infants and children there is a decline in passive external rotation of the shoulder despite the family complying with the external rotation stretch as directed by the physiotherapist. Any decline in passive external rotation of the shoulder is an indication to contact the therapists at The Children’s Hospital at Westmead, Sydney Children’s Hospitals Network who will facilitate an earlier review at the Upper Limb Clinic.

It is important to continue this routine of passive stretches to the shoulder joint into childhood and adolescence. As the child becomes older the stretching program shifts from the parents’ responsibility to the child performing these stretches.


AssessmentAssessment for the child with NBPP is a comprehensive process through which therapists obtain vital information about a child and family which guides the decision making process.14 The World Health Organisation’s International Classification of Functioning, Disability and Health (ICF) domains include body function and structure; participation; activity; personal and environmental factors. Assessments utilised may be relevant to one or more domains of the ICF.

It is recommended that all children with NBPP are assessed by a physiotherapist and occupational therapist. Each profession brings unique clinical skills that complement each other.

The assessment should cover the domains listed below:

Body function and structure – Body function and structure assessment should include:

• Passive range of motion (PROM)

• Active movements, assessments include the: Active Movement Scale Modified Mallet Classification (also known as the Mallet Scale in some publications) Manual Muscle Test (school aged child)

• Motor planning

• Sensation

• Deformity

• Compensatory movements

– Prior to surgical decision, the medical treating team may also utilise:

• Electromyography (EMG)

• Ultrasound

• Computed tomography scan (CT Scan)

• MRI

Activity and participation – Upper limb function: unilateral prehension and bimanual skill development, assessments include Mini Assisting Hand Assessment and Assisting Hand Assessment. The Mini Assisting Hand Assessment has not been developed or standardised for children with NBPP. Despite this, it can provide useful information with regards to bimanual skills development and the use of the affected upper limb.

– Consideration of the impact of developmental disregard on hand use, developmental prehension and function.

– Developmental assessment.

Occupational performance – Self-care

– Preschool/school

– Leisure/sports and play

EnvironmentalChildren with NBPP may be assessed in their home as well as in their daycare, preschool or school environments. The environment includes the physical, social and cultural contexts within which the child operates.


The assessment process In addition to a standard therapy assessment, the assessment for a child with NBPP should include:

History – Maternal history including history of gestational diabetes.

– Birth history including birth weight, shoulder dystocia, trauma, intervention and clavicular or humeral fractures.

Associated presentations may include:

– Horner’s syndrome.

– Phrenic nerve injury.

Observation – Arm position i.e. flail arm or waiter’s tip position.

Waiter’s Tip Position: This classic position includes shoulder adduction and internal rotation, elbow extension, forearm pronation and wrist flexion. This position is often called the “waiter’s tip” because it resembles a food server holding the hand discreetly for a tip.15

– Active movement.

– Function.

Standardised assessments

Active Movement Scale The Active Movement Scale (AMS) is a tool for assessment of motor function in children with NBPP. It is an eight point scale rating different arm movements and can be used with all ages.16

Further information on A Clinician’s guide to using the Active Movement Scale is available from: http://www.helsebiblioteket.no/fagprosedyrer/ferdige/_attachment/247953?_ts=15375981eea&download=true.

Mini Assisting Hand AssessmentThe Mini Assisting Hand Assessment (Mini-AHA) is for children aged 8–18 months. It describes how effectively the child uses the affected hand in collaboration with the non-affected hand during bimanual play. Formal training and accreditation in the use of this assessment is required.17

This assessment has not been developed or standardised for children with NBPP. Despite this, it can provide useful information with regards to bimanual skills development and the use of the affected upper limb.

Further information on the mini-AHA can be obtained at http://www.ahanetwork.se/.

Assisting Hand Assessment The Assisting Hand Assessment (AHA) for children 18 months and up to 12 years is a hand function evaluation instrument, which measures and describes how children with an upper limb disability in one hand use the affected hand with the non-affected hand in bimanual play. It is appropriate to use with children with NBPP. Formal training is required for administration of this assessment.17

Further information on AHA can be obtained at http://www.ahanetwork.se/.

Children’s Hand-use Experience Questionnaire (CHEQ) and Mini-CHEQThe CHEQ is a questionnaire which captures children’s experience of using the affected hand for tasks which usually require the use of two hands. The questions are answered in relation to how independently the task is done and whether one or both hands are used.


The CHEQ is for children 6–18 years and the Mini-CHEQ is for children 3–8 years. It has been developed for children with brachial plexus palsy.

Further information on CHEQ and Mini-CHEQ can be obtained at http://www.cheq.se/.

Hand Assessment for Infants The Hand Assessment for Infants (HAI) is an assessment of hand function which has recently been developed for infants at risk of developing cerebral palsy in the age range 3–12 months. The HAI intends to measure the degree and quality of goal directed actions performed with each hand separately as well as with both hands together. Formal training is required for administration of the HAI. Although this assessment is not specific to NBPP it can provide useful background information to normal infant upper limb development.

Further information on HAI can be obtained at http://www.ahanetwork.se/.

Modified Mallet ClassificationThe Modified Mallet Classification (also known as the Mallet Scale in some publications) is a grading system to document functional changes of the shoulder and arm. It assesses five shoulder movements on a five-point scale. It is useful in children older than two years.18-19

Manual Muscle Test Manual muscle testing is the evaluation of the function and strength of individual muscles and muscle groups based on the effective performance of a movement in relation to the forces of gravity and manual resistance through the available active range of movement.

Manual muscle testing measures muscle strength using a grading system from Grades 1–5. The basic grades are based on three factors: the amount of resistance that can be given manually to a contracted muscle or muscle group; the ability of the muscle or muscle group to move a part through a complete range of motion and evidence of the presence or absence of a contraction of the muscle or muscle group.20

Table 2: Manual Muscle Test21

Grade Manual muscle test

5 Movement against gravity plus full resistance

4 Movement against gravity plus some resistance

3 Completes the available test range of motion against gravity, but tolerates no resistance

2 Completes the range of motion with gravity omitted

1 Slight contractility without any movement

0 No evidence of contractility (complete paralysis)

http://www.cheq.se/http://www.ahanetwork.se/


Role of therapy with a child with NBPPTherapy for children with NBPP should begin as soon as possible after birth to achieve optimal functional outcomes and is essential for both children whose care is being managed conservatively, as well as for children who require surgical intervention. Children with NBPP need input from both physiotherapy and occupational therapy with a focus on specific professional intervention within appropriate scope of practice. Whilst each profession may bring their own expertise it is essential that they work together to optimise the functional outcomes for the child. Therapists can help children with brachial plexus palsy in a variety of ways including:

– Parent education.

– Implementation and monitoring of a stretching program.

– Facilitation of active upper limb movement and strengthening through age appropriate developmental play, activities and games.

– Facilitating age appropriate motor development.

– Development of independence and age appropriate self-care, leisure and sporting activities.

– Splinting and serial casting of the upper limb to reduce contractures, prevent deformity, and assist movement and functional use of the hand.

Working with a child at a specific developmental time means that expectations need to be age appropriate. Activities will change and become more complex as the child gets older.

Model of therapeutic intervention The ICF is a classification system developed by the World Health Organisation that encompasses all aspects of health and describes them in terms of health domains and health related domains.22 Duff & DeMatteo (2015) suggest that as children develop, the focus moves from impairment in infancy to age appropriate activities and participation as preschoolers.23


Table 3: ICF Classification from infancy to adolescence

Infant Toddler Preschool School age Adolescent

Assessment focus

Impairment and environment

Impairment and activity

Impairment, activity and participation

Activity and participation

Participation and activity

Intervention focus

Integration of limb

Range of passive and active motion(ROM) /strength

ROM/strength

Integration

Child motor development

ROM/strength

Hand function

Participation in age related school and leisure activities

Quality of life (QOL)

Participation age related school and leisure activities

QOL

Primary objective

Sensorimotor recovery and function

Hand function

Hand preference

Self esteem

Preschool – prediction of school issues

Hand preference

ROM/strength: interventions

ROM/strength: interventions

Other important considerations

Family

Splinting

Serial casting

Other interventions

Splinting

Serial casting

Other interventions

Splinting

Serial casting

Self-efficacy

Self-esteem

Splinting

Serial casting

Self-efficacy

Self-esteem

Splinting

Serial casting

Personal Factors

Child development Family Family Future planning Future planning

*This table has been adapted from Duff & DeMatteo23


InterventionWhen working with children with NBPP it is important to consider the impact on upper limb and fine motor skills throughout development. Areas affected may include: hand regard, eye hand development, unimanual and bimanual goal directed reach, hands together at midline and the differentiation of roles of each hand. The impact of weakness, limitations in active movement and compensatory movements may lead to reduced awareness, delay in fine motor development of the affected hand, sensory issues and delayed bimanual skill development.

Children with NBPP often achieve functional goals by adopting compensatory strategies. Compensatory movements need to be closely evaluated in light of how the child may be using these compensatory movements to achieve upper limb function. The therapist needs to be aware of the use of these compensatory movements and may choose to focus intervention only within the achievable range of motion. It is valuable to assess the child’s use of compensatory movements when completing functional tasks. It is important to decide if the goal is to retrain these compensatory movements in light of improved muscle strength or determine if the child relies on these compensatory movements to achieve function.

Typical compensatory movements include:

– Extension of the lumbar and thoracic spine to achieve shoulder flexion above 90 degrees to assist upper limb and hand placement when reaching.

– Use of shoulder abduction to facilitate hand to mouth. This is referred to as the ‘trumpet sign’ and demonstrates the weakness of shoulder external rotation and elbow flexion.

– Clinical observation of scapular winging. This may be viewed as a compensatory movement which enables the arm to move further into shoulder abduction and flexion.

The following intervention framework is divided into the key ages for intervention for a child with NBPP. These age-groups may be used as a guide: 0–6 months, 6 months, 9 months, 12 months, 18–36 months, preschool, school and high school age. The frequency of intervention is determined by considering the child’s needs in the context of family and environment.


0–6 months of ageThe physiotherapist and occupational therapist will be seeing the infant regularly to evaluate recovery of the affected upper limb. Assessment should include the Active Movement Scale (AMS) and passive range of motion of the shoulder, elbow, forearm and hand.

Maintenance of passive range of motion of the upper limb, focuses initially on stretches to the shoulder (external rotation) followed by stretches to elbow, forearm, wrist and hand. It is important to carefully prioritise the stretches to ensure parents are not overwhelmed at this time.

Stretching of the shoulder is important as it prevents tightness/contracture of internal rotators of the shoulder (pectoralis major, teres major, latissimus dorsi, anterior deltoid and subscapularis).

The shoulder external rotation stretch is the most important stretch. It is important to spend time ensuring that the parents and care givers are confident doing this stretch for the required amount of time. Generally, it is suggested performing this stretch every nappy change, holding for 20–30 seconds and repeating 5–10 times. This may need to be increased if there is any shoulder tightness experienced when performing this stretch.

Other intervention consists of education focusing on the positioning and handling of the infant. Parents need to be given directions on how to support the arm when handling the child. This may include:

– Dressing: start with affected arm first and for undressing start with the unaffected arm.

– Bathing: support the affected arm while it is being cleaned with particular care to ensure the underarm is washed and dried carefully.

– Feeding: affected arm should be across the baby’s chest when feeding or supported rather than left to fall by the baby’s side.

– Carrying: support affected arm and never allow the affected arm to dangle.

– Tummy time encouraged as part of normal development with the goal of facilitation of bilateral shoulder girdle muscle activity. Position the affected upper limb so that the baby is weight bearing on the forearm. The baby may initially require some support around the shoulder to maintain this position and be comfortable.

– There is no need to immobilise the arm such as tucked into a singlet across the body. This is only necessary if the baby has a humeral or clavicular fracture and immobilisation is usually for 10–14 days.

– Wrist thermoplastic splints for newborn babies are not commonly used unless there is significant wrist and finger flexion posturing. This is mostly managed with gentle stretching program to maintain wrist and finger extension.

Frequency of intervention at this stage depends on the severity of the injury and the family’s ability to carry out the home program. The general recommendation for therapy frequency of intervention is every 2-4 weeks.

If there is no return of function or movement appears to plateau contact should be made with the therapists at The Children’s Hospital at Westmead regarding the need for further specialist consultation and possible referral to the Upper Limb Clinic. Lack of biceps function (elbow flexion) at three months can indicate long term sequelae and a referral should be made to the Upper Limb Clinic at The Children’s Hospital at Westmead, Sydney Children’s Hospitals Network.

Typical developmentTypical development refers to abilities that are expected of a child within that age range without a disability.

– Asymmetrical tonic neck reflex becoming integrated with developing midline orientation and symmetry.

– Hands coming together in the midline.

– Hands loosely open.

– Developing ability to hold toy placed in hand with active grasp.

– Interest in focusing and following moving objects.

– The beginning of swiping movements with the arms and reaching.

– Early development of eye-hand coordination with hands to mouth and hand regard.


– Progressively able to weight bear on forearms in prone with elbows behind shoulders. Head is lifted 45 to 90 degrees off the supporting surface with the child able to freely rotate head.

– Sitting with support.

– Rolls supine to prone and prone to supine by six months. Postural transition with rolling starting to occur by four months.

Skills assessed and intervention provided at this stage addresses: – Unilateral voluntary arm movements moving towards developing unilateral reach and grasp.

– Supine: hands together on body moving towards hands together in space, early development of eye-hand coordination.

– Prone: early weight bearing on forearms.

– Sensory awareness of affected upper limb as fingers touch own face, body and clothes with tactile recognition leading to repetition of these movements.

– Beginning of bringing objects to the mouth.

– Gentle touch and guidance to the affected arm to facilitate active movements.

– Positioning and stimulation of active movements of the upper limb in supine and supported sitting to promote gravity eliminated and against gravity movements should be encouraged.

– Splinting may be required at this age to maintain range of movement, especially if the child has a pan plexus injury where the hand is significantly affected. Infants may present with wrist flexion and a fisted hand at this age. If passive range can be maintained through stretching, then splinting is not indicated. Close monitoring of passive range is required while waiting to determine the degree of recovery.

Resources

Appendix 2: Babies with NBPP: Stretching the shoulderStretching is very important to keep the soft tissues supple and prevent tightness of specific muscle groups.

Understanding Brachial Plexus PalsyThis pamphlet is designed to help parents learn about brachial plexus injuries. http://www.rch.org.au/uploadedFiles/Main/Content/plastic/BRACHIAL_PLEXUS_book.pdf.

About Erb’s PalsyThe Erb’s Palsy Group is a UK based organisation offering advice, information and support to families affected by Erb’s Palsy. http://www.erbspalsygroup.co.uk/.




6–9 months of ageIt is at this stage that the roles of the occupational therapist and physiotherapist become more defined. At this age the infant is developing goal directed reach and unimanual skills as well as early bimanual skill development.


– Increased ability with handling and grasping toys.

– Reaching to pick up or take toy with both hands.

– Objects to mouth.

– Hands to feet in supine.

– Able to pick up a small toy and hold in the centre of palm with all fingers.

– Transferring toys from one hand to another.

– Reach for toy when dropped within arm’s length.

– No asymmetry of hand use is generally seen below nine months of age.

– Prone weight bearing on extended arms.

– Ability to weight shift onto forearm while reaching with the other arm.

– Transitions from sitting to four point position.

– Sitting unsupported with propping on one arm to increase reach.

Skills assessed and intervention provided at this stage addresses:It is important for children with Brachial Plexus Palsy to develop as much active movement and control with the weaker arm and hand as possible. Strategies are provided to encourage the child to use the weaker hand to REACH, open the hand and fingers to GRASP and then practice letting go or RELEASING toys. In this way they are actively using the weaker hand.

– Facilitating active range of movements of the upper limb to the available end of range.

– Unilateral reach and grasp with affected arm (comparison with non-affected arm).

– Encouraging awareness of the affected upper limb through facilitated reach and grasp for objects.

– Palmar grasp – moving towards radial palmar grasp with thumb involved.

– Midline play.

– Transferring toys between hands.

– Weight bearing on forearms in prone. Encourage the ability to weight bear on affected arm or vice versa. Also encourage the ability to reach in this position with the affected arm.

– Ability to bring affected arm out from underneath body in prone lying.

– Beginning of the development of pincer grip with awareness of tiny objects, poking and attempting to rake objects.

– Exploratory movements with hand involving shaking and mouthing of an object.

– Retaining grasp.

– Sensory play.

– Seating for play, fine motor development and feeding.

– Splinting to maintain range of movement if necessary.

– Dynamic splinting or taping to facilitate patterns of movement e.g. wrist in neutral, or active forearm supination.

– Interventions to facilitate use of the affected hand and then link it with bimanual skill development.

– Encourage play in a variety of positions including eliminating gravity when focusing on specific skills. This may include play


encouraging shoulder abduction while in supine or shoulder flexion in side lying, pronation and supination in gravity eliminated positions.

Continue with: – Passive Range of Movement (PROM) stretches into shoulder external rotation, elbow extension and pronation/supination. Please see Appendix 2: Babies with NBPP: Stretching the shoulder.

Resources


Appendix 3: Babies with NBPP: Ways to encourage active movement of the weaker arm It is important for children with Brachial Plexus Palsy to develop as much active movement and control with the weaker arm and hand as possible. Strategies are provided to encourage the child to use the weaker hand to REACH, open the hand and fingers to GRASP and then practice letting go or RELEASING toys. In this way they are actively using the weaker hand.

Appendix 4: Suggested toys for children with NBPPOutline of different types of toys that may be used to facilitate specific skill development.

Developmental and Functional Hand Grasps By: Sandra J. Edwards, Donna J. Buckland, Jenna D. McCoy-Powlen.

Published: Slack Incorporated; 1 edition (November 26, 2002).

This book describes essential developmental, precision, pencil and power grasps. It is a useful resource to identify, illustrate and describe the complexity of grasps.




9–12 months of ageThis is an important age developmentally for baby’s upper limb development and function. They are using both hands for reaching, manipulation and bimanual play.

They are starting to develop their ability to explore their environment through crawling and pulling to stand. This is an essential age for the occupational therapist and physiotherapist to be involved in joint sessions. Depending on the child’s recovery there may be a need for a block of specific intervention at this age. For example, Modified Constraint Induced Movement Therapy (Mod CIMT) intervention to focus on developing improved awareness, use and fine motor skills with the affected arm.

If the child is progressing well monthly reviews may be appropriate.


– Crawling in four point position.

– Reaching in four point position.

– Pulling to stand.

– Developing standing with support and cruising.

– Coordinated bimanual use developing.

– Asymmetry of hand use may begin to develop.

– Drops one of two toys picked up to take third one that is offered.

– Bangs toy in hand on table.

– Holds toy in one hand and play with attached string with other.

– Picks up small toy with tips of fingers.

– Picks up crumb with thumb and index finger.

– Developing active release.

– Feeds self finger-food.

– Hand to mouth.

– Wrist extended during grasp.

Skills assessed and intervention provided at this stage addresses: – Specific intervention focuses on facilitating awareness and active movement of the affected upper limb. This may include Modified Constraint Induced Movement Therapy (Mod CIMT).

– Weaker movements are identified by functional assessment and the Active Movement Scale. These movements should be targeted for specific practise.

– Promotion of end of range active movements such as shoulder abduction/flexion/external rotation, elbow extension and forearm supination.

– Unilateral direct approach to reach and achieving radial digital grasp.

– Hand to mouth with abducted shoulder is often seen due to weakness of against gravity elbow flexion, shoulder external rotation and supination. Even if the child can flex the elbow against gravity, the child may choose not to as gravity eliminated is quicker and easier.

– Encouraging adducted upper arm and hand to mouth assists with strengthening external rotation of the shoulder, elbow flexion and supination to bring hand to mouth. This also prevents the abducted hand to mouth posture becoming habitual.

– Actively extending wrist during grasp.

– Poking with fingers and ability to isolate the index finger to poke especially if there is hand weakness.

– Using an inferior pincer grip and beginning to develop a fine pincer grasp to pick up tiny objects.


– Four point weight bearing on extended arms with reaching. Encourage the ability to weight bear on affected arm or vice versa. Also encourage the ability to reach in this position with the affected arm.

– Learning to drop objects moving towards voluntary release from the affected hand. Important to encourage this as often the child will transfer the object to the unaffected hand (taking it out with the unaffected hand) and then release.

– Continue with the development of age appropriate play.

– Monitoring the need to provide compensatory techniques for fine motor function, particularly when recovery is limited and involvement of the affected upper limb is significant.

– Facilitation of the development of early bimanual skills – especially focused on the role of the affected upper limb. Interventions should facilitate use of the affected hand and then link with bimanual skill development.

Continue with: – Passive Range of Movement (PROM) stretches into shoulder external rotation, elbow extension and forearm pronation/supination. Please see Appendix 2: Babies with NBPP: Stretching the shoulder.

– Encouraging active movement of the weaker arm. Please see Appendix 3: Babies with NBPP: Ways to encourage active movement of the weaker arm.

Resources


Appendix 3: Infants and Babies with NBPP: Ways to encourage active movement of the weaker arm It is important for children with Brachial Plexus Palsy to develop as much active movement and control with the weaker arm and hand as possible. Strategies are provided to encourage the baby to use the weaker hand to REACH, open the hand and fingers to GRASP and then practice letting go or RELEASING toys. In this way they are actively using the weaker hand.


Modified Constraint Induced Movement Therapy and children with NBPP – Section 9.

There is currently some emerging but limited evidence for the use of Constraint Induced Movement Therapy (CIMT) for children with NBPP. When considering the use of Modified CIMT as an intervention it is essential that an occupational therapist is involved.

Developmental and Functional Hand Grasps By: Sandra J. Edwards, Donna J. Buckland, Jenna D. McCoy-Powlen.






12–18 months of ageThis is an important age developmentally for upper limb function both unimanual and bimanual. Children are generally able to stand which gives them the ability to reach higher for toys and objects. It is an age where the child’s prehension development comes into play. The infant’s bimanual skills are developing and expanding. At 12 months an infant is transferring toys smoothly, turning and rotating toys in exploration and showing both symmetrical actions (such as banging two objects together, pulling objects apart) and asymmetrical actions (such as with one hand stabilising and the other hand manipulating). They are beginning to be engaged in their early self-help skills such as pushing an arm through a sleeve, using a spoon, holding a cup to drink.

If the infant has had limited or reduced opportunity to develop bimanual skills a block of occupational therapy intervention would be appropriate to focus on bimanual skill development. Other children may require monthly therapy reviews as appropriate.

Typical development – Attempts to put small toy on top of another.

– Puts a toy in a cup.

– Dangles a toy by a string.

– Releases a toy against surface.

– Helps in dressing, for example, pushing arm through sleeve.

– Uses forearm supination to facilitate grasp.

– Fine pincer grasp developing with small objects held between fingertips.

– Tactile manipulation (rotation, squeezing, transferring) replaces oral exploration.

– Precise release into small container with wrist extended.

– Bimanual skill development requires that each hand perform different, but complementary actions on one or more objects.

– Standing without support.

– Taking steps with progression to independent walking.

Skills assessed and intervention provided at this stage addresses: – Specific intervention focuses on facilitating awareness and active movement of the affected upper limb. This may include Modified Constraint Induced Movement Therapy (Mod CIMT).

– Promotion of end of range shoulder abduction and flexion in reaching.

– Weaker movements are targeted as identified by functional assessment and the Active Movement Scale.

– Strengthening active shoulder external rotation and supination of the forearm so the infant can see the object that they are grasping.

– Fine prehension patterns – precise digital grasp between thumb and two fingers.

– Bimanual development such as combining objects in midline.

– Precise release of objects.

– Interventions to facilitate use of the affected hand and then link with bimanual skill development.

Continue with: – Passive Range of Movement (PROM) stretches into shoulder external rotation, elbow extension and pronation/supination. Please see Appendix 2: Babies with NBPP: Stretching the shoulder.

– Encouraging active movement of the weaker arm. Please see Appendix 3: Babies with NBPP: Ways to encourage active movement of the weaker arm.


Resources


Appendix 5: Children with NBPP: Ways to encourage active movement of the weaker arm It is important for children with Brachial Plexus Palsy to develop as much active movement and control with the weaker arm and hand as possible. Strategies are provided to encourage the child to use the weaker hand to REACH, open the hand and fingers to GRASP and then practice letting go or RELEASING toys. In this way they are actively using the weaker hand.

Modified Constraint Induced Movement Therapy and children with NBPP – Section 9There is currently some emerging but limited evidence for the use of Constraint Induced Movement Therapy for children (CIMT) for children with NBPP. When considering the use of Modified CIMT as an intervention it is essential that an occupational therapist is involved.

Developmental and Functional Hand GraspsBy: Sandra J. Edwards, Donna J. Buckland, Jenna D. McCoy-Powlen.






18 months–3 years of ageAt this age the toddler is starting to develop all of the upper limb functional skills that they need for preschool and their independence at home with self-help skills.

The occupational therapist and physiotherapist play an essential role at this age for children with NBPP. The frequency of intervention will be determined by the level of involvement of the affected upper limb and the impact of this on the child’s awareness and use and everyday functional skills.

Remember that 12-18 months is important for normal development of bimanual hand function, and experiences of developing motor planning. These skills are consolidated between 18 months-3 years with developmental expectation of increasing difficulty of tasks. Children with NBPP often miss out on early bimanual skill acquisition and experiences. So they may not have foundation skills for planning how to use both hands together in a well-coordinated manner.

At this age parents may report that the child is “using” the affected hand, however, when assessed they may place a toy in the affected hand (with the unaffected hand) to hold and carry. When observed in therapy it becomes evident that the child is not actively reaching and grasping a toy from a surface, manipulating, transferring between hands, or releasing with accuracy with the affected hand.

Occupational therapy at this time may include a block of intervention (e.g. Mod CIMT, working on specific functional goals such as toileting, dressing and preschool readiness skills). It is also important to continue combined monthly therapy reviews.


– Scribbles with crayon, holding in a palmar supinate grasp.

– Imitates strokes on a paper.

– Turns pages of book.

– Stacks three small cubes.

– Points to pictures.

– Beginning to use spoon to feed.

– Role differentiated bimanual manipulation skills maturing and includes actions such as unscrewing and unzipping.

– Walking.

– Developing running gait pattern.

– Integration of upper limb skills with gross motor tasks. For example, child can walk pulling a toy on a string.

– Climbing.

– Starting to develop ball skills such as throwing and rolling.

Skills assessed and intervention provided at this stage addresses: – It is important to continue ongoing monitoring regarding the development of fine motor function and particularly of bilateral coordination.

– Enhancing the development of fine motor skills required for preschool, as well as self-care and play skills, for example drawing, manipulation and bilateral skills, eating, and dressing.

– Therapy focused on bimanual play and coordination, especially choosing toys that the child can easily manipulate and hold with the affected hand so that they are successful in using the affected hand as an assistor or non-dominant hand.

– Assessing spontaneous initiation, reaching, holding and spontaneous release with the affected upper limb is important at this age. If the child often places a toy in the affected hand and simply carries it around, or places their large toys between the affected forearm and their body to carry the toy, this may limit use of the affected upper limb. This will indicate that a block of therapy focusing on functional grasp, hold and release is required. The aim is to improve awareness and skill level with the affected hand.

– Modified Constraint Induced Movement Therapy (Mod CIMT) may be appropriate at this stage.

– Development of climbing skills to promote upper limb strength. This may be achieved by support on playground equipment. Attention should be focused on how the child is using the affected upper limb to negotiate the play equipment.

– Use balls of different sizes to develop skills of rolling and throwing concentrating on two handed development and skill development of the affected side.


– Toddler/preschooler group including activities to encourage reach games, weight bearing and supination play.

Continue with: – Passive Range of Movement (PROM) stretches into shoulder external rotation, elbow extension and pronation/supination. Please see Appendix 6: children with NBPP: Stretching the upper limb.

– Encouraging active movement of the weaker arm. Please see Appendix 5: Children with NBPP: Ways to encourage active movement of the weaker arm.

Resources


Appendix 6: Children with NBPP: Stretching the Upper LimbStretching is very important to keep the soft tissues supple and prevents tightness of specific muscle groups.

Appendix 7: Children with NBPP: Ways to encourage the development of two handed (bilateral) coordination From the age of 18 months children’s play increasingly focuses on using their two hands together in more complex ways.

Appendix 8: Children with NBPP: Adducted hand to mouthIdeas to encourage reaching towards the body with arm tucked in.

Appendix 9: Children with NBPP: Encourage active forearm supinationIdeas to encourage active forearm supination.

Appendix 10: Children with NBPP: Encourage active forearm pronationIdeas to encourage active forearm pronation.

Modified Constraint Induced Movement Therapy and children with NBPP – Section 9There is currently some emerging but limited evidence for the use of Constraint Induced Movement Therapy (CIMT) for children with NBPP. When considering the use of Modified CIMT as an intervention it is essential that an occupational therapist is involved.




Preschool age (3–5 years)

The preschooler’s functional upper limb skills are being continually developed and challenged at this age. They are developing school readiness skills for many bimanual tasks, such as drawing, cutting and construction play. They are also moving towards increased independence with their self-help skills for toileting, dressing and eating with utensils. The preschooler is engaged in imaginary play and this can be incorporated into the sessions.

The therapist’s role is essential at this age to support their function at preschool, daycare and at home. Intervention may be provided in a block of therapy to work on specific goals or at three monthly intervals which may include preschool contact or visits. Planning for school transition is also important at this age. The occupational therapist and the physiotherapist may run a School Starters Group to target skills that will be required to begin school.


– Builds a tower of 9–10 small blocks.

– Uses playdough to make balls, snakes, cookies.

– Independently build things with large linking blocks, such as Megablocks or Duplo.

– Draws a circle.

– Copies a cross (+).

– Imitates drawing a square.

– Starts to hold a crayon or pencil with a mature grasp.

– Cuts across a piece of paper.

– Start to cut along a straight line.

– Manages buttons.

– Put on most items of clothing, but may still need help with shirts and jackets.

– Feed self well with a spoon and fork.

– Ball skills such as throwing and catching with some degree of aim.

– Use of scooter and bike.


Skills assessed and intervention provided at this stage addresses: – During this time it is essential to facilitate developmentally appropriate fine motor skills, including participation in preschool tasks (gross and fine motor play).

– It is important to continue ongoing monitoring regarding the development of fine motor function and particularly of bilateral coordination.

– Posture is reinforced for table top activities. The position of the affected arm (if it is being used as the non-dominant hand) should be at the side of the paper with the shoulder in neutral rather than in an internally rotated position with the arm across the body at the bottom of the paper. It is important to reinforce adduction of the upper arm and forearm fully pronated.

– A hand preference usually starts to develop between the ages of two to four years. It is common at this stage for children to swap hands. Between the ages of four to six years a clear hand preference is usually established. For most children they will develop their own preference or hand dominance for holding a utensil to eat, a toothbrush to clean their teeth or a pencil to colour and draw. This is monitored by the occupational therapist without pushing a preference for the non-affected or affected hand. It may take some time for the child to choose which hand will become the dominant hand for handwriting as they progress towards school.

– Issues which can arise in relation to the development of hand dominance include:

• When the affected hand appears to be the dominant hand – the child may begin to colour with this hand and after a short time, swap to the unaffected hand. If the child has underlying grasp weakness, limited active forearm rotation and shoulder weakness, this contributes to fatigue.

• Some children will eventually swap dominance to the unaffected hand. Additional intervention may be required to support hand writing acquisition and motor planning.

• If the child continues to use the affected hand for handwriting considerations need to be given to monitoring handwriting acquisition, fatigue management and handwriting speed as they progress through school.

• If the affected hand is the non-dominant hand – clear choice will be made with the unaffected hand being used to hold a crayon using an age appropriate grasp.

– Adaptive equipment may be required to support function during table top activities such as slope board to assist with stabilising work or pencil grips.

– Participation in self-help skills and developing independence with dressing, eating, toileting and management of belongings in preparation for school.

– Encourage the development of ball skills through catching and throwing with balls of different sizes.

– Discuss with parents and provide modifications to enable riding of scooters or bikes.

– Discuss with parents involvement of child in gross motor recreational activities that are age appropriate and promote the use of the upper limb i.e. swimming lessons, dancing and gymnastics.

– Continue encouragement of using playground equipment to strengthen upper limb by climbing.

Continue with: – Encouraging the development of two handed (bilateral) coordination. Please see Appendix 5: Children with NBPP: Ways to encourage active movement of the weaker arm. Please see Appendix 7: Children with NBPP: Ways to encourage the development of two handed coordination.

– Encouraging the adducted hand to mouth by tucking the arm into the side. Please see Appendix 8: Children with NBPP: Adducted hand to mouth.

– Encouraging active forearm supination. Please see Appendix 9: Children with NBPP: Encouraging active forearm supination.

– Encouraging active forearm pronation. Please see Appendix 10: Children with NBPP: Encouraging active forearm pronation.


Resources

I Can Do It Myself: Dressing and other daily living skills for children with one-armed weakness This booklet offers strategies and tips to help children with one-arm weakness adapt to their daily activities. It has been written for parents, caregivers, therapists, and teachers of children with Neonatal Brachial Plexus Palsy. It will provide a useful, easily reproducible booklet that is suitable for carers and schools.

This booklet, developed by SickKids can be downloaded free of charge from: https://assets.aboutkidshealth.ca/akhassets/I_can_do_it_myself.pdf.



Appendix 11: Children with NBPP: Encouraging active elbow extension with reaching activities It is important to provide opportunities in play for children with NBPP to actively extend the arm when reaching and facilitate end of range active reaching.

Appendix 12: Children with NBPP: Getting Ready for School This handout provides useful information on posture, pencil grasp and cutting for the child beginning preschool.

Appendix 13: Template of Letter for PreschoolA template for a letter suitable for preschool has been provided. This is useful to facilitate communication with preschool. It is important that this letter outlines general information regarding Brachial Plexus Palsy, impact on functional performance within the preschool and suggestions regarding support.



https://assets.aboutkidshealth.ca/akhassets/I_can_do_it_myself.pdf


School age (4–7 years)The school aged child’s functional upper limb skills are being continually developed and challenged at this age. They are developing skills for many bimanual tasks, such as drawing, writing, cutting and construction play. They are also moving towards increased independence with their self-help skills for toileting, dressing, eating with utensils and managing their own belongings.

The therapist’s role is essential at this age to support the child’s function at school and at home. Intervention may be provided in a block to work on specific goals or at three monthly intervals. This may include school visits or communication with school when appropriate.

Typical DevelopmentTypical development refers to abilities that are expected of a child within that age range without a disability.

– Start to use one hand consistently for fine motor tasks.

– Use the tips of the fingers and the thumb together in a precise pinch or pincer grasp.

– Assume and use some form of tripod pencil grasp, where a writing tool is held between the tips of the thumb, index finger, and middle finger (versus a whole hand grasp).

– Draw a circle, triangle, square, and a recognisable picture of a person and a house.

– Start to colour inside the lines of a picture.

– Cut around reasonably complex designs such as a combination of straight and curved.

– Use one hand to stabilise an object and the other to perform a separate activity such as unscrewing a lid and doing up buttons.

– Manipulate small objects within the hand.

– Build things with smaller linking blocks, such as Duplo or Lego.

– Independent in many self-care tasks such as simple dressing, toileting, and managing their lunch box.

– Developing their ability to tie shoe laces.

– Start to spread butter or cut soft foods with a small table knife (with supervision).

– Continue integration of upper limb with gross motor skill development.

– Throw a small ball with dominant hand.

– Participation in sport and active leisure activities.

Skills assessed and intervention provided at this stage addresses: – Participation in self-help skills and developing independence with dressing, eating, toileting and management of belongings in preparation for school.

– Posture in sitting for table top tasks to ensure symmetrical positioning of the affected arm on the table top, neutral shoulder position, forearm pronation to stabilise work.

– Participation in school readiness program to ensure that an updated assessment is conducted and that a report is available for school which documents the NBPP injury, impact, precautions and support which may be required at school.

– Continued development of ball skills which may involve movement in space.

– Development of more complex gross motor skills such as skipping with a skipping rope.

– Encourage participation in recreational activities that promote upper limb strength and coordination such as swimming and active leisure activities.

Continue with: – Passive Range of Movement (PROM) stretches into shoulder external rotation, elbow extension and forearm pronation/supination.


Resources



Appendix 14: Template of Letter for Starting School A template for a letter suitable for school has been provided. This is useful to facilitate communication with school. It is important that this letter outlines general information regarding NBPP, impact on functional performance within the school and suggestions regarding support.




Primary and high school ageThe primary and high school aged child’s functional upper limb skills are being continually developed and challenged at this age. It is essential at this age to support the child and young person’s function at school and at home. The therapist needs to monitor passive range of motion of the shoulder, elbow or forearm range. In addition, issues related to discomfort and pain in the shoulder, back or arm should be addressed. At this age reduced use of the affected hand during functional tasks can become more evident as the child or young person is expected to be acquiring greater independence. Intervention may be provided in a block to work on specific goals and may include school contact or visits as appropriate.


– School aged children 6-12 years old should have mastered hand and eye coordination.

– Should be able to use eating utensils and other tools, manage their self-care including tying own hair, washing underarms and be able to help with household chores.

– Drawing, painting, and engaging in making crafts.

– Continued development of writing skills.

– Children and young people will continue to refine their fine motor skills through adolescence with activities such as sports, crafts, hobbies, learning musical instruments, computer use, and video games.

– Children and young people should be extending fine motor and coordination skills through participation in all leisure and sport activities with families and peers.

Skills assessed and intervention provided at this stage addresses: – Assisting with activities of daily living as expectations for independence increase. If the child’s or young person’s ability to reach up, rotate the shoulder or hand function is affected then tasks such as tying shoe laces, washing and brushing hair, washing and shaving under arms and using deodorant can be an ongoing challenge.

– Some children will have reduced shoulder internal rotation, which can cause difficulty with:

• Placing the affected hand on their stomach or at their side

• Doing up shirt buttons

• Doing up trouser buttons and belts

• Pulling up trousers on the affected side as quickly as is required, for example to change for sports.

– Issues which can become more challenging if the young person has reduced reach range and shoulder strength include:

• Assisting with household tasks which require reaching up

• Carrying larger objects e.g. hanging out or taking in washing, wiping up dishes and carrying a tray.

– Specific support may be required at times of transition, such as moving to high school. A school visit or contact may be required to support the school and assist in problem solving with the student’s safe participation in practical subjects such as design and technology subjects.

– It is important to continue to monitor handwriting issues as the student progresses through school and expectations of quantity and speed increase. If the young person uses the affected arm for handwriting then fatigue can become more evident as they progress through upper primary and high school.

– Specific blocks of therapy and goal setting to focus on:

• Using the affected hand

• The young person taking an increased role in completing their own initiated stretching program

• For the younger school age child, using reward charts and photo programs can be useful. Herbie and His Special Arm published by the Erb’s Palsy UK group provide useful examples of how to do this.

– Functional splints may assist with hand function.

– Provision of adaptive equipment may facilitate active participation and achievement.

guide for therapists...this injury is traditionally known as erb’s palsy when c5 and c6 are...

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