Journal of Hand Therapy 27 (2014) 335e340
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
JHT READ
FOR
CREDIT ARTICLE #331.
Practice Forum
Sup-ER orthosis: An innovative treatment for infants with birth related brachial plexus injury Kim M. Durlacher MRSc, BScOT, CHT a, b, c, *, Doria Bellows BScPT d, Cynthia Verchere MD, FRCSC e, f, g a
Department of Occupational Therapy, British Columbia Children’s Hospital, Vancouver, Canada Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada Department of Physical Therapy, University of British Columbia, Vancouver, Canada d Department of Physiotherapy, British Columbia Children’s Hospital, Vancouver, Canada e Division of Pediatric Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, Canada f Department of Surgery, University of British Columbia, Vancouver, Canada g Child & Family Research Institute, Vancouver, Canada b c
Impairments in active and passive range of upper extremity supination and shoulder external rotation are common sequelae for children with delayed recovery from birth related brachial plexus injury. Orthotic intervention may complement traditional treatment strategies commonly employed in the newborn period. These authors describe their custom fabricated orthosis designed to balance shoulder growth and muscular function, and improve prognosis of long term functional outcomes for children with birth related brachial plexus injury. e VICTORIA PRIGANC, PhD, OTR, CHT, CLT, Practice Forum Editor .
Birth related brachial plexus injury (BRBPI) occurs in 0.9e4.6/ 1000 births globally,1e6 with spontaneous recovery of functional levels reported to occur in 50e92% of patients.1,2,6e9 Almost universal outcomes of BRBPI, even for children with otherwise “good” recovery, are impairments in both active and passive range of upper extremity supination (Sup) and shoulder external rotation (ER).4,6,10 Poorly positioned (Fig. 1) and contracted shoulder musculature, and associated skeletal changes can secondarily prevent full range of even otherwise recovered muscle action, and potentially result in significant functional consequences.9 While awaiting maximal nerve recovery, traditional treatment goals have included prevention of joint contractures, strengthening of recovering muscles, sensory stimulation, and encouraging developmental milestones.9 Ter Steeg, Hoeksma, Dijkstra, Nelissen & De Jong (2003) reported that shoulder bracing for BRBPI was recommended in the first half of the twentieth century, but subsequently advised against with inference made to concerns related to the development of shoulder ER and abduction contractures associated with orthotic * Corresponding author. BC Children’s Hospital Occupational Therapy Department e Rm K1-200, 4480 Oak Street, Vancouver, Canada V6H 3V4. Tel.: þ1 604 875 2123; fax: þ1 604 875 3220. E-mail address: [email protected] (K.M. Durlacher).
use, and henceforth is seldom mentioned in modern literature.10 However, orthotic use is described by Chan (2002) as one of the most useful modalities to prevent joint contractures, minimize deformities, and substitute loss of motor control following a peripheral nerve injury.11 Ter Steeg et al (2003) concluded that the use of arm braces “during the period of flaccid palsy of the shoulder muscles be reconsidered, but could only be justified after a randomized clinical trial” (p. 7).10 Purpose of this orthosis Our clinic team speculated that if the arm could be practically, safely, and comfortably supported for the majority of the day in a position of the most glenohumeral congruity achievable and with the tightest muscles held lengthened (i.e. into forearm supination and shoulder external rotation) then the normal anatomic growth of the shoulder may be better maintained until nerve recovery allowed for active movement to return.12 Indications for use of the Sup-ER orthosis (Fig. 2) include infants presenting with major weakness or tightness of shoulder ER, beyond the recovery period anticipated for a neuropractic injury. At our center, based on clinical assessment of the child at about 4e8 weeks of age, defining criteria include tightness in passive range of motion of shoulder external rotation (any angle of less than 180 from the
0894-1130/$ e see front matter Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jht.2014.06.001
336
K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340
Fig. 3. Waistband pattern.
2 D-rings and rivets, or thermoplastic hooks Hapla fleece Super wrap by Fabrifoam Fig. 1. Typical arm resting posture in BRBPI.
Fabrication abdomen in ER), and/or, using the Toronto Active Movement Scale,13 a score of ER 2, and/or Sup 2.12 Materials used 1.6 mm aquaplast (or preferred light weight thermoplastic), preferably not perforated Neoprene plush Velcro - Hook and loop - Adhesive and non-adhesive
Fig. 2. Right arm Sup-ER orthosis (With kind permission from Springer Science and Business Media).12
Waistband See Fig. 3 for pattern and required measurements. Trace pattern and cut out neoplush. Sew Velcro closures to waist band and nappy strap (Fig. 8). Long arm orthosis 1. To create a pattern, measure the baby’s arm length from the distal metacarpal phalanges to top of the humerus, and arm circumference at largest part. This will give you a rectangular pattern. Cut out thermoplastic. 2. Punch a hole for the thumb, positioned about 1 inch from long edge and 3/4 inch from width edge of thermoplastic. 3. With the arm positioned in 15e20 wrist extension, and maximum tolerated supination and elbow extension, slide thumb through the hole and mold the thermoplastic on the anterior surface of the arm/hand, wrapping circumferentially to secure the thermoplastic in place while positioning. Stay as high up the arm as possible. 4. Once thermoplastic has cooled, remove from the infant’s arm and trim edges as needed. Do not trim the thumb hole too large as the orthosis may rotate on the hand if the infant is resisting the supinated position. Clear the distal palmar crease. Cut proximal end on an angle to optimize orthotic length laterally without impinging on the axilla. 5. Line edges with hapla fleece (for comfort). 6. Anchor Velcro strap across dorsal hand (Fig. 4), to assist caregivers in securing the orthosis on the arm. 7. Attach Velcro straps (using rivet and D-ring for added adjustability, or thermoplastic hook) at (1) lateral elbow, and (2) proximal/anterior aspect (Fig. 6). These straps should be long enough to extend from the orthosis to the posterior aspect of the trunk, to secure the arm in SUP and shoulder ER when the baby is lying supine.
K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340
337
(Figs. 6 and 7). You may also cut slits in the wrap to thread the Dring through. Note: The direction of pull of the wrap and maintaining arm supination while wrapping are key to maintaining the supination position of the arm. Part 2 1. Apply the waistband, pulling the nappy strap up between the legs, like a diaper (Figs. 8 and 9). 2. Gently move the shoulder into ER and secure the Velcro straps from the top of the arm and elbow to the posterior aspect of the waistband (Fig. 10). Note: Always position the shoulder with your hands, using straps to secure. Do not use straps to pull the shoulder into position. Wear schedule
Fig. 4. Apply orthosis (With kind permission from Springer Science and Business Media).12
Assembly Part 1 1. With the palm facing up (supination), apply the orthosis to the anterior aspect of arm/hand (Fig. 4). 2. Secure soft Velcro strap over dorsum of hand. 3. With the arm still in supination, apply the super wrap. Thread thumb through the hole that you have cut approximately 1½ inches from the end, with end of the wrap pointing into the palm (Fig. 5). Loop wrap around the hand, and through a second thumbhole to secure. Apply gentle even tension, with pull in the direction of supination. Overlap the wrap by approximately half its width as you proceed up the arm, avoiding the hooks/D-rings
Fig. 5. Apply wrap.
The recommended wear schedule will depend on the infant’s age and clinical assessment. Ideally orthotic use is initiated by 3 months of age, up to 6 months of age. While the orthosis may be introduced to older babies, tolerance to use (and thus family participation) may present a greater challenge with more established contractures and/or patterns of movement of the involved limb. An intensive period of full time orthotic use (i.e. 22 h per day) is typically recommended initially, to build acceptance to wear, and optimize the orthotic benefits during the infant period. During this stage parents are instructed to remove the entire orthosis at least two times per day to perform range of motion exercises, encourage age appropriate developmental activities, and address skin care needs. Additionally, removal of the shoulder Velcro straps (Part 2) is recommended when the child is feeding or traveling in a car seat. This schedule is gradually tapered to night and nap times to promote increasing opportunities for age appropriate developmental stimulation in the growing child.
Fig. 6. Strap placement.
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K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340
Fig. 7. Wrap complete.
Regular monitoring and assessment of the child’s condition and orthotic fit are important to maintain efficacy of orthotic positioning and fit, and to support individual developmental progress and recovery from BRBPI. Caregiver education and participation are keys to successful implementation of this orthotic program. The importance of continued range of motion exercises, sensory stimulation, and age appropriate developmental play, in addition to orthotic use, are emphasized.
Fig. 8. Waistband.
Early findings A recent pilot study of the Sup-ER orthosis protocol12 completed at our center demonstrated the Sup-ER group final score at two years of age was better than controls by 1.18 Toronto Active Movement Scale13 points in Sup and 0.96 Toronto Active Movement Scale13 points in ER. In addition, an unexpected finding was that no subjects during the study period were assessed to have the active functional criteria to indicate brachial plexus reconstruction, when previously 13% were operated on at our center. Summary In combination with active physiotherapy, use of the Sup-ER orthosis to passively position the affected arm into external
Fig. 9. Waistband application complete.
Fig. 10. Rotation strap application (With kind permission from Springer Science and Business Media).12
K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340
rotation and supination for recommended periods of time during infancy, may have a positive effect on balanced shoulder growth, muscular function, and prognosis for long term outcomes in patients presenting with BRBPI. Formalized outcome studies are currently in development. References 1. Hardy AE. Birth injuries of the brachial plexus: incidence and prognosis. J Bone Joint Surg Br. Feb 1981;63-B(1):98e101. 2. Rubin A. Birth injuries: incidence, mechanisms, and end results. Obstet Gynecol. Feb 1964;23:218e221. 3. Levine MG, Holroyde J, Woods Jr JR, Siddiqi TA, Scott M, Miodovnik M. Birth trauma: incidence and predisposing factors. Obstet Gynecol. Jun 1984;63(6): 792e795. 4. Hoeksma AF, Wolf H, Oei SL. Obstetrical brachial plexus injuries: incidence, natural course and shoulder contracture. Clin Rehabil. Oct 2000;14(5):523e526. 5. Chauhan SP, Rose CH, Gherman RB, Magann EF, Holland MW, Morrison JC. Brachial plexus injury: a 23-year experience from a tertiary center. Am J Obstet Gynecol. Jun 2005;192(6):1795e1800. discussion 1800e1792.
339
6. Lagerkvist AL, Johansson U, Johansson A, Bager B, Uvebrant P. Obstetric brachial plexus palsy: a prospective, population-based study of incidence, recovery, and residual impairment at 18 months of age. Dev Med Child Neurol. Jun 2010;52(6):529e534. 7. Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF. The natural history of obstetrical brachial plexus palsy. Plast Reconstr Surg. Apr 1994;93(4): 675e680. discussion 681. 8. Gilbert A. Repair of the brachial plexus in the obstetrical lesions of the newborn. Arch Pediatr. Mar 2008;15(3):330e333. 9. Waters PM. Update on management of pediatric brachial plexus palsy. J Pediatr Orthop B. Jul 2005;14(4):233e244. 10. ter Steeg AM, Hoeksma AF, Dijkstra PF, Nelissen RG, De Jong BA. Orthopaedic sequelae in neurologically recovered obstetrical brachial plexus injury. Case study and literature review. Disabil Rehabil. Jan 7 2003;25(1):1e8. 11. Chan RK. Splinting for peripheral nerve injury in upper limb. Hand Surg. Dec 2002;7(2):251e259. 12. Verchere C, Durlacher K, Bellows D, Pike J, Bucevska M. An early shoulder repositioning program in birth-related brachial plexus injury: a pilot study of the Sup-ER protocol. Hand. March 2014;9(2):187e195. http://dx.doi.org/ 10.1007/s11552-014-9625-y. 13. Curtis C, Stephens D, Clarke HM, Andrews D. The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy. J Hand Surg Am. May 2002;27(3):470e478.
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K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340
JHT Read for Credit Quiz: #331
Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question. #1. The article identifies the following as commonly problematic motions with birth related brachial plexus injuries a. supination and internal rotation b. external rotation and supination c. pronation and supination d. internal and external rotation #2. Spontaneous functional recovery is reported at approximately a. 25e50% b. 95% c. 75% d. 50e90% #3. One of the primary aims of the orthosis is to rest the upper extremity in a position which facilitates a. minimum brachioradialis activity b. minimum teres minor activity
c. maximum glenohumeral congruity d. maximum biceps relaxation #4. The following may be accurately said of this work: it is a a. completed study with solid findings b. preliminary investigation with encouraging findings c. case study d. a clinical report with no intension being viewed through a scientific lens #5. The name Sup-ER is a clever play on the word super a. true b. false When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
JHT READ
FOR
CREDIT ARTICLE #331.
Practice Forum
Sup-ER orthosis: An innovative treatment for infants with birth related brachial plexus injury Kim M. Durlacher MRSc, BScOT, CHT a, b, c, *, Doria Bellows BScPT d, Cynthia Verchere MD, FRCSC e, f, g a
Department of Occupational Therapy, British Columbia Children’s Hospital, Vancouver, Canada Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada Department of Physical Therapy, University of British Columbia, Vancouver, Canada d Department of Physiotherapy, British Columbia Children’s Hospital, Vancouver, Canada e Division of Pediatric Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, Canada f Department of Surgery, University of British Columbia, Vancouver, Canada g Child & Family Research Institute, Vancouver, Canada b c
Impairments in active and passive range of upper extremity supination and shoulder external rotation are common sequelae for children with delayed recovery from birth related brachial plexus injury. Orthotic intervention may complement traditional treatment strategies commonly employed in the newborn period. These authors describe their custom fabricated orthosis designed to balance shoulder growth and muscular function, and improve prognosis of long term functional outcomes for children with birth related brachial plexus injury. e VICTORIA PRIGANC, PhD, OTR, CHT, CLT, Practice Forum Editor .
Birth related brachial plexus injury (BRBPI) occurs in 0.9e4.6/ 1000 births globally,1e6 with spontaneous recovery of functional levels reported to occur in 50e92% of patients.1,2,6e9 Almost universal outcomes of BRBPI, even for children with otherwise “good” recovery, are impairments in both active and passive range of upper extremity supination (Sup) and shoulder external rotation (ER).4,6,10 Poorly positioned (Fig. 1) and contracted shoulder musculature, and associated skeletal changes can secondarily prevent full range of even otherwise recovered muscle action, and potentially result in significant functional consequences.9 While awaiting maximal nerve recovery, traditional treatment goals have included prevention of joint contractures, strengthening of recovering muscles, sensory stimulation, and encouraging developmental milestones.9 Ter Steeg, Hoeksma, Dijkstra, Nelissen & De Jong (2003) reported that shoulder bracing for BRBPI was recommended in the first half of the twentieth century, but subsequently advised against with inference made to concerns related to the development of shoulder ER and abduction contractures associated with orthotic * Corresponding author. BC Children’s Hospital Occupational Therapy Department e Rm K1-200, 4480 Oak Street, Vancouver, Canada V6H 3V4. Tel.: þ1 604 875 2123; fax: þ1 604 875 3220. E-mail address: [email protected] (K.M. Durlacher).
use, and henceforth is seldom mentioned in modern literature.10 However, orthotic use is described by Chan (2002) as one of the most useful modalities to prevent joint contractures, minimize deformities, and substitute loss of motor control following a peripheral nerve injury.11 Ter Steeg et al (2003) concluded that the use of arm braces “during the period of flaccid palsy of the shoulder muscles be reconsidered, but could only be justified after a randomized clinical trial” (p. 7).10 Purpose of this orthosis Our clinic team speculated that if the arm could be practically, safely, and comfortably supported for the majority of the day in a position of the most glenohumeral congruity achievable and with the tightest muscles held lengthened (i.e. into forearm supination and shoulder external rotation) then the normal anatomic growth of the shoulder may be better maintained until nerve recovery allowed for active movement to return.12 Indications for use of the Sup-ER orthosis (Fig. 2) include infants presenting with major weakness or tightness of shoulder ER, beyond the recovery period anticipated for a neuropractic injury. At our center, based on clinical assessment of the child at about 4e8 weeks of age, defining criteria include tightness in passive range of motion of shoulder external rotation (any angle of less than 180 from the
0894-1130/$ e see front matter Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jht.2014.06.001
336
K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340
Fig. 3. Waistband pattern.
2 D-rings and rivets, or thermoplastic hooks Hapla fleece Super wrap by Fabrifoam Fig. 1. Typical arm resting posture in BRBPI.
Fabrication abdomen in ER), and/or, using the Toronto Active Movement Scale,13 a score of ER 2, and/or Sup 2.12 Materials used 1.6 mm aquaplast (or preferred light weight thermoplastic), preferably not perforated Neoprene plush Velcro - Hook and loop - Adhesive and non-adhesive
Fig. 2. Right arm Sup-ER orthosis (With kind permission from Springer Science and Business Media).12
Waistband See Fig. 3 for pattern and required measurements. Trace pattern and cut out neoplush. Sew Velcro closures to waist band and nappy strap (Fig. 8). Long arm orthosis 1. To create a pattern, measure the baby’s arm length from the distal metacarpal phalanges to top of the humerus, and arm circumference at largest part. This will give you a rectangular pattern. Cut out thermoplastic. 2. Punch a hole for the thumb, positioned about 1 inch from long edge and 3/4 inch from width edge of thermoplastic. 3. With the arm positioned in 15e20 wrist extension, and maximum tolerated supination and elbow extension, slide thumb through the hole and mold the thermoplastic on the anterior surface of the arm/hand, wrapping circumferentially to secure the thermoplastic in place while positioning. Stay as high up the arm as possible. 4. Once thermoplastic has cooled, remove from the infant’s arm and trim edges as needed. Do not trim the thumb hole too large as the orthosis may rotate on the hand if the infant is resisting the supinated position. Clear the distal palmar crease. Cut proximal end on an angle to optimize orthotic length laterally without impinging on the axilla. 5. Line edges with hapla fleece (for comfort). 6. Anchor Velcro strap across dorsal hand (Fig. 4), to assist caregivers in securing the orthosis on the arm. 7. Attach Velcro straps (using rivet and D-ring for added adjustability, or thermoplastic hook) at (1) lateral elbow, and (2) proximal/anterior aspect (Fig. 6). These straps should be long enough to extend from the orthosis to the posterior aspect of the trunk, to secure the arm in SUP and shoulder ER when the baby is lying supine.
K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340
337
(Figs. 6 and 7). You may also cut slits in the wrap to thread the Dring through. Note: The direction of pull of the wrap and maintaining arm supination while wrapping are key to maintaining the supination position of the arm. Part 2 1. Apply the waistband, pulling the nappy strap up between the legs, like a diaper (Figs. 8 and 9). 2. Gently move the shoulder into ER and secure the Velcro straps from the top of the arm and elbow to the posterior aspect of the waistband (Fig. 10). Note: Always position the shoulder with your hands, using straps to secure. Do not use straps to pull the shoulder into position. Wear schedule
Fig. 4. Apply orthosis (With kind permission from Springer Science and Business Media).12
Assembly Part 1 1. With the palm facing up (supination), apply the orthosis to the anterior aspect of arm/hand (Fig. 4). 2. Secure soft Velcro strap over dorsum of hand. 3. With the arm still in supination, apply the super wrap. Thread thumb through the hole that you have cut approximately 1½ inches from the end, with end of the wrap pointing into the palm (Fig. 5). Loop wrap around the hand, and through a second thumbhole to secure. Apply gentle even tension, with pull in the direction of supination. Overlap the wrap by approximately half its width as you proceed up the arm, avoiding the hooks/D-rings
Fig. 5. Apply wrap.
The recommended wear schedule will depend on the infant’s age and clinical assessment. Ideally orthotic use is initiated by 3 months of age, up to 6 months of age. While the orthosis may be introduced to older babies, tolerance to use (and thus family participation) may present a greater challenge with more established contractures and/or patterns of movement of the involved limb. An intensive period of full time orthotic use (i.e. 22 h per day) is typically recommended initially, to build acceptance to wear, and optimize the orthotic benefits during the infant period. During this stage parents are instructed to remove the entire orthosis at least two times per day to perform range of motion exercises, encourage age appropriate developmental activities, and address skin care needs. Additionally, removal of the shoulder Velcro straps (Part 2) is recommended when the child is feeding or traveling in a car seat. This schedule is gradually tapered to night and nap times to promote increasing opportunities for age appropriate developmental stimulation in the growing child.
Fig. 6. Strap placement.
338
K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340
Fig. 7. Wrap complete.
Regular monitoring and assessment of the child’s condition and orthotic fit are important to maintain efficacy of orthotic positioning and fit, and to support individual developmental progress and recovery from BRBPI. Caregiver education and participation are keys to successful implementation of this orthotic program. The importance of continued range of motion exercises, sensory stimulation, and age appropriate developmental play, in addition to orthotic use, are emphasized.
Fig. 8. Waistband.
Early findings A recent pilot study of the Sup-ER orthosis protocol12 completed at our center demonstrated the Sup-ER group final score at two years of age was better than controls by 1.18 Toronto Active Movement Scale13 points in Sup and 0.96 Toronto Active Movement Scale13 points in ER. In addition, an unexpected finding was that no subjects during the study period were assessed to have the active functional criteria to indicate brachial plexus reconstruction, when previously 13% were operated on at our center. Summary In combination with active physiotherapy, use of the Sup-ER orthosis to passively position the affected arm into external
Fig. 9. Waistband application complete.
Fig. 10. Rotation strap application (With kind permission from Springer Science and Business Media).12
K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340
rotation and supination for recommended periods of time during infancy, may have a positive effect on balanced shoulder growth, muscular function, and prognosis for long term outcomes in patients presenting with BRBPI. Formalized outcome studies are currently in development. References 1. Hardy AE. Birth injuries of the brachial plexus: incidence and prognosis. J Bone Joint Surg Br. Feb 1981;63-B(1):98e101. 2. Rubin A. Birth injuries: incidence, mechanisms, and end results. Obstet Gynecol. Feb 1964;23:218e221. 3. Levine MG, Holroyde J, Woods Jr JR, Siddiqi TA, Scott M, Miodovnik M. Birth trauma: incidence and predisposing factors. Obstet Gynecol. Jun 1984;63(6): 792e795. 4. Hoeksma AF, Wolf H, Oei SL. Obstetrical brachial plexus injuries: incidence, natural course and shoulder contracture. Clin Rehabil. Oct 2000;14(5):523e526. 5. Chauhan SP, Rose CH, Gherman RB, Magann EF, Holland MW, Morrison JC. Brachial plexus injury: a 23-year experience from a tertiary center. Am J Obstet Gynecol. Jun 2005;192(6):1795e1800. discussion 1800e1792.
339
6. Lagerkvist AL, Johansson U, Johansson A, Bager B, Uvebrant P. Obstetric brachial plexus palsy: a prospective, population-based study of incidence, recovery, and residual impairment at 18 months of age. Dev Med Child Neurol. Jun 2010;52(6):529e534. 7. Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF. The natural history of obstetrical brachial plexus palsy. Plast Reconstr Surg. Apr 1994;93(4): 675e680. discussion 681. 8. Gilbert A. Repair of the brachial plexus in the obstetrical lesions of the newborn. Arch Pediatr. Mar 2008;15(3):330e333. 9. Waters PM. Update on management of pediatric brachial plexus palsy. J Pediatr Orthop B. Jul 2005;14(4):233e244. 10. ter Steeg AM, Hoeksma AF, Dijkstra PF, Nelissen RG, De Jong BA. Orthopaedic sequelae in neurologically recovered obstetrical brachial plexus injury. Case study and literature review. Disabil Rehabil. Jan 7 2003;25(1):1e8. 11. Chan RK. Splinting for peripheral nerve injury in upper limb. Hand Surg. Dec 2002;7(2):251e259. 12. Verchere C, Durlacher K, Bellows D, Pike J, Bucevska M. An early shoulder repositioning program in birth-related brachial plexus injury: a pilot study of the Sup-ER protocol. Hand. March 2014;9(2):187e195. http://dx.doi.org/ 10.1007/s11552-014-9625-y. 13. Curtis C, Stephens D, Clarke HM, Andrews D. The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy. J Hand Surg Am. May 2002;27(3):470e478.
340
K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340
JHT Read for Credit Quiz: #331
Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question. #1. The article identifies the following as commonly problematic motions with birth related brachial plexus injuries a. supination and internal rotation b. external rotation and supination c. pronation and supination d. internal and external rotation #2. Spontaneous functional recovery is reported at approximately a. 25e50% b. 95% c. 75% d. 50e90% #3. One of the primary aims of the orthosis is to rest the upper extremity in a position which facilitates a. minimum brachioradialis activity b. minimum teres minor activity
c. maximum glenohumeral congruity d. maximum biceps relaxation #4. The following may be accurately said of this work: it is a a. completed study with solid findings b. preliminary investigation with encouraging findings c. case study d. a clinical report with no intension being viewed through a scientific lens #5. The name Sup-ER is a clever play on the word super a. true b. false When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.
