Iran J Pediatr. 2017 December; 27(6):e5679. doi: 10.5812/ijp.5679.
Published online 2017 November 20. Research Article
The Relationship between Range of Motion and Function of Upper
Extremity in Obstetric Brachial Plexus Palsy Patients Treated with
Tendon Transfer
Zeynep Hosbay,1,* Muberra Tanrıverdi,2 Ela Tarakci,2 Atakan Aydın,3 and Arzu Razak Ozdincler2
1Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Bezmialem Vakif University, Istanbul, Turkey
2Department of Plastic Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
3Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul University, Istanbul, Turkey
*Corresponding author: Zeynep Hosbay, PhD, PT, Vatan Caddesi, 34093, Fatih, Istanbul, Turkey. Tel: +90-5055034279, Fax: +90-2124531870, E-mail: zeynephosbay@gmail.com
Received 2016 March 20; Revised 2017 June 12; Accepted 2017 October 02.
Abstract
Obstetric brachial plexus palsy (OBPP) refers to upper limb paralysis secondary to a sustained traction or compression injury to the brachial plexus during birth. The
reported incidence in developed countries is 2 per 1000 live births. The assessment and planning of appropriate treatment is important in the early stages of OBPP. The aim
of our study was to examine the relationship between the range of motion and upper extremity function of the shoulder in patients with OBPP who were treated by tendon
transfer. This study included 48 patients who had shoulder tendon transfer at least 6 months ago in Istanbul Medical Faculty, Department of Plastic and Reconstructive
Surgery, Department of Surgery of the Hand. Range of motion measurements were performed using a universal goniometer and the modified mallet classification was
used to categorize global shoulder function. Pediatric evaluation of disability inventory (PEDI) and Canadian occupational performance measure (COPM) were used to
evaluate functional ability, activity and participation. When examining relationships between range of motion and functional scores, there was a statistically significant
relationship between COPMP score and external rotation, and no relationship was found between other motion functional scores. The study demonstrated that, the use
of the pattern of development and motivation of patients to participate is also important among range of motion and muscle strength for upper extremity function.
Keywords: Brachial Plexus, Upper Extremity, Range of Motion
1. Background 2. Objectives
The aim of our study was to examine the relation-
Obstetric brachial plexus palsy (OBPP) refers to upper
ship between the range of motion and upper extremity
limb paralysis secondary to a sustained traction or com-
function of the shoulder in patients with OBPP who were
pression injury to the brachial plexus during birth. The re-
treated with tendon transfer.
ported incidence in developed countries is 2 per 1000 live
births (1). Risk factors for OBPP include shoulder dystocia,
high gestational age, forceps delivery, and clavicle fracture. 3. Methods
The shoulder dystocia has been identified as the greatest
risk factor (2). Although 96% recover spontaneously, a sub- A total of 57 patients with OBPP were invited for this
set of individuals demonstrate persistent neurological and cross sectional study. Five patients refused to participate
functional deficits due to muscle weakness, soft tissue con- in the study. Four assessments were incomplete and were
tractures, and structural deformities. omitted. Therefore, the study completed with 48 patients
The assessment and planning of appropriate treat- (20 girls and 28 boys).
ment is important in the early stages of OBPP. Conservative The mean age was 6.1± 1.4 years and birth weight 4210
and surgical treatment approaches are not alternative, but ± 496.91 kg. In 26 patients right side was involved and 22
complementary to each other. Conservative and surgical patients had left side involvement. In 17 (35.4 %) patients
treatments both aim to improve the functional level of the the palsy was of C5-6 type, in 30 (62.5 %) patients of C5-7,
organ. and in 1 (2.1 %) patient of C5-T1.
Modified Hoffman technique is used to increase shoul- Children 4 - 8 years of age had underwent an opera-
der abduction and external rotation in children with OBPP. tion useing Modified Hoffer Tecnnigue at least 6 month
After this surgery technique, despite that patients have in- ago. This technique is used to increase shoulder abduction
creased abduction and external rotation, they do not pre- and external rotation with latissimus dorsi and teres major
fer to use the upper limb in their daily living activities (3). transfers to strengthen external rotation combined with
Copyright © 2017, Iranian Journal of Pediatrics. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0
International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the
original work is properly cited.
Hosbay Z et al.
subscapularis lengthening, reduction of posterior disloca- 3.5. Canadian Occupational Performance Measure (COPM)
tion or subluxation, and humeral osteotomy, if necessary COPM is a tool that determines a person’s role in the
(3-5). problems faced in the performance. It is used to measure
performance of the patient during an activity with a sat-
3.1. Assessment isfaction score given by the patient. In the first step the
3.1.1. Demographic Characteristics family is asked to determine the difficulties of the child’s
The medical history of the patients was collected via daily living activities. In the second step parents are asked
a demographic form prepaired by us. The form included; to score these activities according a Likert scale between 0
patient’s name and surname, age, gender, type of delivery, and 10 (0 = not important, 10 = very important). In the third
birth weight, dominant side of injury, accompanying in- step the family and child are asked to determine the 5 most
juries. important activities for the child and score them by Likert
scale between 0 and 10 for each activity. Thus, performance
3.2. Range of Motion and satisfaction scores for children’s activities are identi-
Range of motion measurements were performed by us- fied by parents. The last score is calculated by dividing the
ing a universal goniometer. Shoulder abduction and flex- total performace and satisfaction scores by the number of
ion measurements were performed on standing to avoid activities (10-12).
compensatory movements and to be able to observe the
spine. Shoulder external and internal rotation movements 3.6. Statistical Analysis
were performed lying prone to be able to stabilize the Statistical analysis were performed by using the SPSS
scapula. Other ROM measurements were performed us- software package (version 21.0; SPSS, Inc., Chicago, IL, USA)
ing standard techniques. First measurements were shown for Windows. We performed a power analysis to deter-
on unaffected side to the patient and then performed on mine the sample size at the beginning of the study. Be-
the affected extremity. Measuremented followed Kendall- fore the statistical analysis, Kolmogorov-Smirnov test was
Mc Creary criterias. Each measurement was repeated three used to test for normal distribution of data. Descriptive
times and average value recorded (6). statistics were used to determine differences of subjects’
demographic and clinical features. Intercorrelations be-
3.3. Mallet Classification tween parameters were computed with Pearson’s correla-
The modified Mallet classification was utilized to cat- tion analysis. A correlation coefficient between 0.26 and
egorize global shoulder function. Patients were asked to 0.49 reflects poor agreement, those between 0.50 and 0.69
perform actively five different shoulder movements: ab- reflect moderate agreement, and those≥ 0.70 reflect high
duction, external rotation, placing the hand behind the agreement. P values < 0.05 were considered as statistically
neck, placing the hand as high as possible on the spine, and significant.
placing the hand to the mouth. Each shoulder movement
was subsequently graded on a scale of I (no movement) 4. Results
to V (normal motion symmetric to the contralateral, un-
affected side) (Figure 1) (7). Gross function evaluation was The mean and range of motions are presented in Table
preferred because muscle testing and sensory assessments 1. The results of Mallet, PEDI and COPM are shown in Table
are not suitable for children and infants. Mallet classifica- 2. The relationship between range of motion and upper ex-
tion system and modifications are frequently used. This tremity function is presented in Table 3.
system provides us to follow the results of microsurgery When examining relationships between range of mo-
and revision surgery results in obstetric brachial plexus tion and functional scores, the only statistically significant
palsy in literature (8). relationship existed between COPMP score and external ro-
tation (r = -0.31 P = 0.04). There was no other significant re-
3.4. Pediatric Evaluation of Disability Inventory (PEDI) lationship between movements and functional scores (Ta-
PEDI is used to evaluate functional abilities. PEDI con- ble 3).
sists of 3 parts which are functional skills, caregiver assis-
tance and modifications. Functional skills is a measure 5. Discussion
of the functional capacity of the child. Functional ability
scale contains 197 items. Self-care, mobility and social func- We investigated the relationship between upper ex-
tions are sub-titles of the scale. Each item is scored as 0 or tremity functions and shoulder range of motion after
1 (9). shoulder tendon transfer in children with brachial plexus.
2 Iran J Pediatr. 2017; 27(6):e5679.
Hosbay Z et al.
Figure 1. Mallet Classification System
Table 1. Shoulder Movements of Patinets tation of COMPS.
The limitation of participation in the activity of upper
X ± SD, ° Min-Max extremity with obstetric brachial plexus palsy is the main
Abduction 139.89 ± 23.50 80 - 180 problem (13, 14). The aim of all treatments of the issue is to
improve functional levels, although in the literature there
Flexion 137.39 ± 24.53 80 - 180
are few studies on function of upper extremity.
External Rotation 74.16 ± 13.50 50 - 95
The range of motion measurement is important for pa-
Internal Rotation 5.20 ± 19.07 -20 - 70 tients with OBPP. Surgery increases range of motion (6, 15,
16). Dedini et al. assessed the range of motion and the
amount of using upper extremity in daily life after first
Table 2. Functional Scores of Patients
year of shoulder tendon transfer. They found a strong cor-
± relation between the increase in shoulder abduction andX SD Min-Max
external rotation as well as the amount of using the ex-
Mallet 17.56 ± 1.14 14 - 20
tremity in daily living activities (15).
PEDI 186.66 ± 10.87 137 - 197 Functional tests are used to evaluate efficiance of re-
COPMP 5.05 ± 2.30 0.6 - 10 habilitation in children with DBBP. Mallet scale assesses
COPMM 5.43 ± 3.12 0 - 10 shoulder functions and general movement patterns. It has
been used to determine efficacy of both surgical and con-
servative treatment methods. We believe there is need for
We found statistically significant differences between the studies to evaluate functions related to shoulder abduc-
shoulder abduction of Mallet scales, shoulder abduction, tion.
flexion and internal rotation of PEDI, shoulder external PEDI has been found to be psycometric because it eval-
and internal rotation of COPMP, and shoulder external ro- uates activity understoodand participation. Self care sub-
Iran J Pediatr. 2017; 27(6):e5679. 3
Hosbay Z et al.
Table 3. Relationships Between Range of Motion and Functional Scores
Mallet Shoulder abd Shoulder flek ER IR PEDI COMPP COMPS
Pearson Correlation 1 0.314a 0.257 0.065 0.184 0.409b 0.282 0.193
Mallet Sig. (2-tailed) 0.030 0.077 0.659 0.210 0.004 0.052 0.189
n 48 48 48 48 48 48 48 48
Pearson Correlation 0.314a 1 0.879b -0.116 0.453b 0.579b 0.199 -0.009
Shoulder abd Sig. (2-tailed) 0.030 0.000 0.433 0.001 0.000 0.174 0.949
n 48 48 48 48 48 48 48 48
Pearson Correlation 0.257 0.879b 1 -0.013 0.493b 0.410b 0.116 -0.055
Shoulder flek Sig. (2-tailed) 0.077 0.000 0.930 0.000 0.004 0.433 0.713
n 48 48 48 48 48 48 48 48
Pearson Correlation 0.065 -0.116 -0.013 1 -0.086 -0.101 -0.412b -0.372b
ER Sig. (2-tailed) 0.659 0.433 0.930 0.561 0.494 0.004 0.009
n 48 48 48 48 48 48 48 48
Pearson Correlation 0.184 0.453b 0.493b -0.086 1 0.394b 0.334a 0.185
IR Sig. (2-tailed) 0.210 0.001 0.000 0.561 0.006 0.020 0.209
n 48 48 48 48 48 48 48 48
Pearson Correlation 0.409b 0.579b 0.410b -0.101 0.394b 1 0.447b 0.343a
PEDI Sig. (2-tailed) 0.004 0.000 0.004 0.494 0.006 0.001 0.017
n 48 48 48 48 48 48 48 48
Pearson Correlation 0.282 0.199 0.116 -0.412b 0.334a 0.447b 1 0.868b
COMPP Sig. (2-tailed) 0.052 0.174 0.433 0.004 0.020 0.001 0.000
n 48 48 48 48 48 48 48 48
Pearson Correlation 0.193 -0.009 -0.055 -0.372b 0.185 0.343a 0.868b 1
COMPS Sig. (2-tailed) 0.189 0.949 0.713 0.009 0.209 0.017 0.000
n 48 48 48 48 48 48 48 48
a Correlation is significant at the 0.05 level (2-tailed).
b Correlation is significant at the 0.01 level (2-tailed).
title can be applied alone because mobility and social func- bathing and dressing activities communicated by the fami-
tions are not affected in children with OBPP (9, 17). PEDI has lies. There is also a significant relationship between COMPS
disadvantages due to only interested in the task has been scores and shoulder external rotation.
acomplished or not, and it doesnt evaluate the quality of We found a correlation between Mallet, PEDI and COPM
the performance. PEDI can be used to evaluate the relation- scores. There is a relationship between different parame-
ship between self care and actitivities related to shoulder ters of functional tests and range of motion.
abduction, flexion, and internal rotation.
Our study has some limitations. It was a single cen-
COPM has been used to evaluate functionality within
ter study, thus it cannot have wide applicability. A multi-
pediatric rehabilitation field. COPM is rarely used in Turkey
centered study is required for more reliable results, even
even for research, yet its use has been the standard tool
though the assessments completed by one physiotherapist
in clinical practice in various countries. This is the rea-
increase the reliability of the use of instrument. In addi-
son we used it in our study. COPM can be used to as-
tion, there were no healthy controls to compare.
sess play and self care activities in children. It is recom-
mended to perform the assessment in children younger We believe that upper extremity functions are not only
than 8 years of age by the family. We performed the as- related to muscle strenght and range of motion, they are
sessment of children 4-8 years old with their families in also needed for the pattern of developement and motiva-
our study. There is only one study with children that used tion of the patient for participating in rehabilitation pro-
COPM in Turkey. Bumin et al. found significant relation- cess.
ship between COPM and PEDI scores, and report that COPM Istanbul faculty of medicine clinical research ethics
is a valid instrument in children with develepomental dis- committee, dated 23.12.2011, No. 08 meeting of the
orders (12). We found a significant relationship between 2011/2103-891 with the number of files received approval
COMPP scores and shoulder abduction, external and in- and were conducted in accordance with the Declaration of
ternal rotation movements; we think that it is related to Helsinki.
4 Iran J Pediatr. 2017; 27(6):e5679.
Hosbay Z et al.
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