Study of the armfunction and follow-up of children from the region Groningen with conservative treated obstetric brachial plexus palsy.

Abstract
Goal the examination of the function of the arm of children, 4 till 16 years
old, who have an obstetric brachial plexus palsy (OBPP). The examination
includes muscle strength, joint flexibility, and arm skills. Also the
participation level and the follow-up will be looked at. Method: The joint
flexibility will be measured with an goniometer and the muscle strength with an
handheld dynamometer. The arm skills will be examined by the hand coordination
of the Movement ABC 2 and ethe bilateral coordination of the BOT 2. There will
be an questionnaire for the participation level and the follow-up.

Reason
The reason to start this study is an experience in the child physiotherapist
praxis with some older children with an OBPP who had shoulder problems. The arm
function was not so good as it was described in older letters from the
paediatrician. There was an difference between the right and the left arm
according to the joint flexibility and the muscle strength. It turned out that
their hadn*t been looked at the arm since they were pre-schoolars.
It is interesting to look to the arm function of children with an OBPP and how
the follow-up has been.
In 2004 in the AMS in Amsterdam there has been a study under children with OBPP
to look to the neurological outcome, the possible complications and the
possible predicting factors. The joint flexibility and shoulder deformities
were measured. The outcome was that shoulder complications occur more often
than had been thought. The pathology of these complications is not clear. The
participation level and the follow-up hadn*t been looked at. In Groningen the
follow-up is at this moment in different hospitals.


Degrees of nerve lesions

Classification of Seddon:3
1 neuropraxis:
the nerve is functionally damaged and passes temporarily no electric signals.
The damage recovers spontaneously within a few days.
2 axonotmesis:
the axons are damaged, but the epi- and perineurium are intact. The nerve
fibres are damaged but when they recover, the perineurium leads the growing of
the fibres in the right direction.
3 neurotmesis:
The axon and the epi- and perineurium are broken. When the fibres recover there
is nothing to lead the growth. There occurs a neurom. There will be no
spontaneous recovery possible.
4 root avulsion:
The nerve has been pulled out of the spinal cord. Distally there will occur a
Wallerse degeneration. The ventral root will be destroyed.


Clinical outcome OBPP

1 Erbs-Duchenne
Erb*s disease. Damage of spinal nerve C5-C6.
2 Erb
Damage of C5-C6-C7.
3 Klumpke-Dèjérine
Damage of C5-C6-C7-C8 en T1.
4 Total palsy
All cervical nerves are damaged.


Medical policy
An OBPP will be found after the delivery. There is a great variety in severity
an complexity of the damage. The children will be examined by a paediatrician.
The severity is not clear in the beginning. After the examination the
physiotherapist for children will start the treatment. The parents have to do
exercises with their child.
In the beginning the paediatrician will examine the child every 3 weeks. They
follow the flowdiagram for eventually sending the child to a *plexusteam* in
Leiden, Amsterdan or Heerlen for an operation. For this study only the children
who did not need an operation are included.

The goal of this study is to describe the function of the arm of older children
with an OBPP in terms of joint flexibility, muscle strength and active
function. Also describe the participation level and the follow-up. This to look
if the follow-up should be changed.

Study program

The parents of the children will be asked to take part in this study by calling
them. The phone calls are made by the treading paediatrician and
physiotherapist for children. When the parents think positive about the study
they will be send an information paper to read about the study. Afterwards they
can decide to take pard in this study. They are also asked to give permission
for using the results for scientfic research. The parents and the children can
withdraw their permission at any time.
The examinations include:
The hand coordination part of M-ABC 2 and the bilateral coordination of the BOT
2. The joint flexibility and the muscle strength will be measured. Afterwards
there is an questionnaire about the participation level (CAPE) and the follow-up
The M-ABC 2, BOT 2 and the CAPE will look to the difference with healthy
children of the same age. By the joint flexibility and muscle strength will be
looked ot the difference between the two arms.
The whole examination will take about 1,5 hour.

The examinatin of the arm is done by tools with are normally used by a child
physiotherapist. There are no additional risks for the children.
The benefit fot the children is a good examination af their arm and the
possibility to ask questions about their arm