Treatment
Treatment of Brachial Plexus Injuries
The good news about brachial plexus injuries is that treatment can make a major difference in how well your child recovers from these injuries and how well he or she learns to adapt to and function with the injuries. We are fortunate that there are a large number of well educated and skilled professionals who can help you and your child achieve the best possible outcome when this serious impairment has occurred.
It is extremely important, though, to remember that early intervention and proper therapy are critical for maximizing your child’s potential.
The sections below will discuss the types of professionals to consult; when to consult them, and the types of treatment that may be available. Obviously, though, since every child is unique, what professional(s), the timing, and what type(s) of treatment your child in particular will need depends on the nature and extent of his or her injuries. Those decisions have to be made in consultation with your child’s treating physician(s).
And when preparing for that consultation, or more than one, make a list of questions in advance. Actually write them down, not just tell yourself, “Oh, I need to remember to ask….”. Perhaps your doctor will answer all your questions anyway before you get to the “Do you have any questions?” part, but if he or she doesn’t, you have your list. A caring professional will take the time to make sure all of your questions are answered, and that you understand the recommendations being made. It’s also a good idea to have both parents present whenever possible, so that you can be sure not to miss anything.
When Should It Start
When do you seek help?
The answer is simple: Immediately.
As soon as you learn your child has a brachial plexus injury locate a brachial plexus clinic and get an appointment. Don’t wait on insurance. Don’t wait for a referral from your pediatrician, obstetrician or family practice doctor. But if a referral is necessary, be assertive about getting one and getting one now. It’s true that honey may be better, but vinegar is sometimes necessary. Get the referral and get started with treatment by people who know what they are doing. In our view delay can result in your child missing important opportunities for treatment or surgery.
Primary Surgery Nerve Grafting
Primary surgery is an attempt to actually “fix” or “restore” some nerve function, especially in infants with partial ruptures (avulsions). Primary surgery involves going directly to the brachial plexus and carefully looking to see exactly what the injury is. After viewing the plexus and the damage, the surgeon will often perform a “neurolysis,” which means the surgeon will literally dissect the nerve tissue, without removing scar tissue, in the hope that this will allow better conduction of nerve impulses.
Another possibility is a nerve graft procedure. That involves taking a superficial nerve from the baby’s calf and transplanting that nerve to the brachial plexus. Just like you use a jumper cable to move electricity from a good battery to a “dead” battery, a nerve graft helps to move nerve impulses from the good end of the nerve to the nerve downstream, bypassing the injured area in between. A nerve graft may help, because it can restore some nerve supply, but it is not a cure for the injury, since a degree of weakness and decreased function will persist.
The brachial plexus surgeon may also consider a nerve transfer, where a portion of a good working nerve is split off to supply the flow lost from the damaged nerve.
But because there is a relatively narrow window of time within which primary surgery is thought to be effective, early diagnosis and evaluation by a physician with expertise in brachial plexus injury is important. If there is no significant improvement in your child’s first three or four months, many physicians will advocate primary surgery. After your child reaches one year many surgeons do not think that primary surgery will be successful.
Secondary Surgery
Secondary surgery is aimed at helping treat the consequences of the reduced nerve supply, such as restoring some function to the nerve or reducing pain, rather that restoring nerve function itself.
Mod Quad/Tendon Transfers
Decreased flow of nerve impulses (decreased innervation) causes strength reduction and atrophy of muscles in the shoulder and upper arm. Proper joint function and movement depends upon the strength of the muscles that surround the joint. Where there are stronger muscles with normal nerve supply and weaker muscles with an impaired supply, as in much of life, the strong overpowers the weak, leading to restrictions in movement around the joint. The goal of various muscle transfer procedures, which transfer muscles from the thigh to the affected area, is to restore some balance to the forces acting across the joint.
Tendon transfer procedures
Another way to restore some balance across the joint is to transfer tendons from the stronger muscle to the other side of the joint. This can be done with tendons across the shoulder, elbow or wrist joints.
Humeral Osteotomies
This procedure name is a combination of three words: derotation (turning back); humeral (relating to the arm bone/humerus) and osteotomy (cutting). This surgery involves cutting bone in order to rotate the humerus back into its proper position.
Triangle Tilt Surgery
This procedure is done to restore the arm to a more neutral position, by shifting the location of the collar bone (clavicle) and shoulder blade (scapula). The procedure helps improve shoulder function and reduce dislocation of the shoulder joint.
Occupational & Physical Therapy
These therapies are helpful in strengthening your child’s muscles, reducing atrophy, improving range of motion, and reducing scar tissue formation that causes contractures in muscles and around joints. (“Contracture” is different from “contraction” and means a static muscle shortening due to things like muscular imbalance or a loss of motion in the adjacent joint.) Therapists work to help the injured child adapt to their limitations and maximize functions for activities of daily living by improving fine motor skills and learning how to perform tasks safely.
Home Exercise and Therapy
Your occupational or physical therapist will give you exercises that are to be done at home. Ask questions to make sure you understand exactly what you are to do, when you are to do it and the specific goal of each exercise. The importance of strictly following the home therapy program cannot be over-emphasized. An occupational or physical therapist coming to your home, or to whom you take your child, can only do so much within the comparatively short times they are available each week to work with your child. Stretching and range of motion exercises help prevent contractures and help prevent scar tissue from forming across joints.
One of the most difficult problems with home exercise and therapy is keeping your child motivated. Doing this isn’t easy, and it can be painful…for your child, or you. So if your child starts to get discouraged, doesn’t want to exercise, consult your doctor, your physical and occupational therapists to get ideas about how to keep them enthusiastic (or at least cooperative) and motivated. Sometimes parents give up when they have to force their children to cooperate.
Don’t let that happen to you. Your child is depending on you to help maximize his or her ability to use the injured arm. Don’t let your child down.
Botox
Thanks to perhaps overly frequent references in movies and television shows, “Botox” has become almost a household term, even though the actual meaning may not be well known. Botulinum toxin (thus the contraction to/origin of the brand name “Botox”) is a protein produced by clostridium botulinum bacterium, and can cause paralysis. In small doses it is used for medical purposes. Children with brachial plexus injuries may be given small doses of Botox to partially paralyze or weaken uninjured muscles around joints, in order to give the weaker muscles a chance to become stronger and more functional.
Water Therapy
Aquatic therapy is just what it sounds like—exercise that is performed in water. Not your bathtub, of course, but in a pool. The aquatic therapist who will work with your child is generally an occupational or physical therapist who has received additional training to work in this therapeutic area.
One of the benefits of aquatic therapy is that the buoyancy of water helps support your child’s weight, and provides a gentle kind of resistance that helps to strengthen muscles without using weights. It is often use for therapy for patients with orthopaedic conditions, of those with neurological disorders that affect joint or muscle integrity or movement, such as might follow from a brain injury. It has the potential to improve your child’s breath control, and increase his or her endurance and the strength of large and small muscle groups. And your child doesn’t even have to know how to swim in order to use aquatic therapy. The therapist will provide flotation devices.
Whether aquatic therapy will provide any benefit at all for your child’s particular condition, or whether it should be in conjunction with land-based exercise programs, is something only you, in consultation with your child’s physician(s) can decide. Always get approval from the appropriate physician(s) before starting any kind of therapy program.
Emotional Support
Unless the injury is a minor one which heals quickly, a brachial plexus child—your child—is going to need years of intense medical care. Frequent visits to doctors and hospitals, as well as repetitive, often boring because of the repetition, occupational and physical therapy are individually and collectively going to be traumatic. The pain associated with the surgeries that will most likely be needed is extraordinarily difficult for a child to comprehend, much less accept and try to rise above. And a brachial plexus injury doesn’t change the fact that your child is a normal human being who is going to experience some degree of frustration, anger, fear and even depression.
Yes, depression. All too often adults think that depression is something that only affects other adults (certainly not me!) or those moody teenagers with their messed up hormones. But it can and does happen in children.
Once your daughter is old enough to understand she’ll never be able to do all of the things with her injured arm that she sees all the other, uninjured, children doing; once your son realizes “I’m different”—that’s when you need to be most alert for potential psychological or emotional problems in your child.
We’re certainly not saying that every child with a brachial plexus injury is going to become clinically depressed. But your child is going to go through some rough emotional times. You need to be aware of the possibilities. You need to be prepared to provide the emotional or other support (including psychiatric or psychological treatment) necessary to help your child get through the emotional upheavals and help him or her develop a healthy self-esteem.
The best support can often come from a counselor who is experienced with the issues of having a special needs child or from other families who have experienced, or are currently experiencing, the same things as you and your child. A local support group can be very helpful for the entire family. Also, thanks to the Internet and search engines like Google, you can more readily locate resources to help provide emotional support for your child.
Summer Camp & Other Activities
Pause a moment, and take a look at a brief slideshow of the fun our brachial plexus children and their families have at our annual summer camp.
A brachial plexus injury is not the end of the world, though there will certainly be times that your child and you are going to feel that way, especially when it comes to physical activities. While it’s true that a brachial plexus injury creates some physical limitations, your child can still enjoy a wide range of physical activities outdoors—for fun, not just for therapy.