Medical Treatment

Medical treatment of brachial plexus palsy includes diagnosis, ongoing assessment, and appropriate therapy.

Initial Management

Medical treatment of brachial plexus palsy begins with the following steps:

diagnosis by neurologic examination
identification of associated injuries
education of the family about the disease and therapy
daily range of motion exercises
monthly assessment of motor strength
for infants with persistent weakness, referral to Brachial Plexus Center before 2 months of age

Assessment

The infant's muscle strength and arm and hand movements are measured every month during the first 6 months. We use three grading systems to document muscle strength and functions of the upper extremities.

Motor Strength Assessment Scale

The Modified British Council Scale for muscle strength, illustrated below, is used for semiquantitative assessment of an infant's muscle strength.

1 - No or trace muscle contraction
2 - Muscle contraction without gravity
3 - Muscle contraction against gravity
4 - Muscle contraction against resistance
NG - Not graded due to difficulties

This muscle strength grading system is applied to each muscle group of the affected upper extremity, as shown below:

Muscle	Strength
Deltoid
Shoulder external rotators
Shoulder internal rotators
Biceps
Triceps
Wrist flexors
Wrist extensors
Finger flexors
Finger extensors

Joint Movement Grading

This grading system allows for quantitative documentation of the joint movement.

Observation	Central Grade	Numerical Score
No joint movement	0	0
Flicker of movement	0+	0.3
Less than half range	1-	0.6
Half range of movement	1	1.0
More than half range	1+	1.3
Good but not full range	2-	1.6
Full range of movement	2+	2.0

(Note: The best movement observed during evaluation is graded.)

This joint movement grading system is then applied to specific movements of each joint of the affected upper extremity, and a total numerical score is found.

Joint Movement	Central Grade	Numerical Score
Shoulder adduction
Shoulder abduction
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
Finger flexion
Finger extension
Total Numerical Score

By recording these objective data for muscle strength and joint movement, a patient's progress can be followed through a series of examinations.

Mallet Scale

Another grading system to document functional changes of the shoulder and arm is the Mallet Scale, which is very useful in children older than two years. (Because it requires the cooperation of the patient, it is not suitable for younger children.) Click on the image to see a larger version.

Physical Therapy

In all infants with brachial plexus palsy, early therapeutic intervention is important. At the initial evaluation at the Brachial Plexus Palsy Center, physical and occupational therapists evaluate the infant as a team. Therapists instruct parents on home exercises and help set up regular local therapy, if necessary.

Exercises provided by the therapists are designed to help improve muscle strength, preserve flexibility and mobility of joints, and protect joint integrity. Splints may be recommended to help improve joint position, function and/or to stretch a tight muscle. The therapists concentrate on caregiver education and training because of the importance of understanding and doing the exercises several times a day at home.

For the child 3 years and older, recommendations for adaptive tools or instructions for alternative techniques for Activities of Daily Living (ADL’s) may be issued to help increase the child’s independence in various skills, such as self-feeding or dressing. The therapists may recommend community activities like swimming, dance, martial arts, musical instruments or adaptive bicycles. These activities can be motivating for children of various ages and levels of severity.

Physical therapy is the only treatment necessary under these conditions: