Table of Contents

    Topic review

    Obstetric Brachial Palsy

    View times: 52
    Submitted by: Rocio Palomo-Carrión


    Obstetric Brachial Palsy (OBP) is defined as a partial or total flaccid paralysis that affects the upper limb of the newborn due to brachial plexus injury occurring in normal delivery, and, more rarely, in cesarean section, often associated with shoulder dystocia

    1. Introduction

    OBP results from injury to the cervical roots C5–C8 and thoracic root T1[1] with <1% of births. It is a serious complication, whose occurrence increases considerably to 6% in cases of fetuses weighing >4000 g[2][3].

    There are different classifications of OBP in terms of anatomical location: upper, intermediate, lower, and total plexus palsy[1]. Upper plexus palsy involves C5, C6, and sometimes C7. Also called Erb’s palsy, it is the most common type of brachial plexus injury (47% of all OBP cases reported) [1][4][5]. It presents with an adducted arm, which is internally rotated at the shoulder. The wrist is flexed, and the fingers are extended, resulting in the characteristic “waiter’s tip” posture. Intermediate plexus palsy involves C7 and sometimes C8 and T1[6][1][7]. Lower plexus palsy involves C8 and T1[1][6][8]. Also called Klumpke paralysis, it is very rare, with 2% of all OBP cases reported[1]. The main clinical feature is poor hand grasp, whereas more proximal muscles are intact[1][6]. Total plexus palsy involves C5–C8 and sometimes T1[1][6], and it is the second most common type of OBP injury[8] [8]. It is the most devastating plexus injury: the infant is left with a clawed hand and a flaccid and insensate arm.

    Clinical findings can be classified into four categories, according to Narakas[9][10]: Group I (C5–C6 paralysis of the shoulder and biceps brachii), Group II (C5–C7 paralysis of the shoulder, biceps brachii, and forearm extensors), Group III (C5–T1 complete paralysis of the limb) and Group IV (complete paralysis of the limb with Horner’s syndrome)[9][10].

    The right arm is more frequently involved due to the more prevalent left occipitoanterior position at delivery[1][11].

    2. Treatment

    Conventional Mirror Therapy (conventional MT) and Virtual Reality Mirror Therapy (Virtual Reality MT) are two therapeutic strategies whose goal is to improve the affected upper limb functionality and the quality of life in different disorders, including OBP, and both can be performed at home to reduce the parental stress and increase the family-child interaction[12].

    Mirror therapy (MT) is a rehabilitation strategy based on the repeated use of the mirror illusion (MI). Patients train by looking into a mirror placed along their midline and hiding their defective limb. The observed reflection of the unimpaired limb superimposes itself on the defective one, thus generating the visual illusion of a functional limb. MT was initially devised as a strategy to alleviate phantom limb pain in amputees before being applied as a neurorehabilitation approach for hemiparetic adults after stroke[13]. There is increasing evidence from randomized controlled trials regarding the effectiveness of MT for improving upper limb motor function, activities of daily living and pain, at least as an adjunct to normal rehabilitation for adults after stroke[14]. In children with hemiplegia, a single pilot clinical trial demonstrated that MT may increase the strength of the paretic arm and improve its dynamic function[15]. The mechanism believed to underlie MT is its effect on “learned paralysis”, in which conflicts between motor efferences and reafferent sensory feedbacks impede motor function[13]. Every time a motor command is sent to the paretic limb, the returning visual and proprioceptive signals inform the brain that the arm is not moving as expected. The aim of mirror visual feedback is to restore the congruity between motor efferences and visual afferences, allowing the subject to unlearn the “learned paralysis”[13]. The effect of the MI could be observed in patients with hemiplegia or another upper limb affectation and in TD subjects[16].The mechanism believed to underlie MT is its effect on “learned paralysis”, in which conflicts between motor efferences and reafferent sensory feedbacks impede motor function[13]. Every time a motor command is sent to the paretic limb, the returning visual and proprioceptive signals inform the brain that the arm is not moving as expected. The aim of mirror visual feedback is to restore the congruity between motor efferences and visual afferences, allowing the subject to unlearn the “learned paralysis” [13]. The effect of the MI could be observed in patients with hemiplegia or another upper limb affectation and in TD subjects[16].

    When an individual observes an action, his/her motor system generates an internal representation of the same action, being recruited similarly relative to its execution. This matching mechanism—named mirror mechanism—is thought to be a key substrate of action understanding and imitation[17]. The functional properties of the mirror mechanism indicate that the motor processes and representations that are primarily involved in generating and controlling a given behavior can also be recruited in an individual who is observing someone else displaying that behavior[17]. Thus, mirror neurons fire both when an individual observes an action and when he/she performs a similar action[18]. An observation/execution matching mechanism facilitates the corticospinal pathway, and it is used to improve the motor function; thus, a “mirror box” is a means to facilitate action observation and, therefore, mirror visual feedback is thought to activate the mirror neuron system in a similar way to action observation[19]. Observing an action elicits in the observer’s brain a motor representation of the outcome to which the action is directed, and this motor representation is similar to what would occur if the individual him/herself was planning that action or even just imagining performing it[20][21]. This would allow the individual to identify the goal of the observed action relying mainly on her or his own motor processes and representations[22]. In line with this, in neurological diseases, action observation is thus able to access the motor system, favoring cortical reorganization and ultimately affecting motor abilities[23][24][25]. Such an approach, known as Action Observation Treatment (AOT), has proven effective in improving upper limb motor abilities in several neurological diseases, presenting the advantage of being applicable also at the patient’s own home[25].

    Conventional MT is a low-cost, non-invasive therapy that allows upper limb rehabilitation, mostly used in adult stroke patients and, to a lesser extent, in pediatric patients with hemiplegia. It generates benefits in joint position, improves the modulation of the proximal muscles and increases muscle activity, as a result of the recruitment of motor units due to the optical illusion created by the mirror[13][14][15]. MT could be combined with virtual reality, since this therapy has shown upper limb changes (grasp strength, bimanual coordination, etc.) in children with cerebral palsy[26]]. Virtual Reality may offer individuals the chance to interact and train with or within interesting and relatively realistic three-dimensional (3D) environments[27]. This allows the intensive repetition of meaningful tasks[28], in a more interesting and autonomous manner than conventional therapy [29]. It is a motivating and entertaining way to engage children in the therapy[30], while enabling the practice and repetition of movements[29][31]]. Virtual Reality MT (using immersive glasses) allows the child to integrate into a virtual environment through external devices[27], which, together with mobile applications, represent a great advance in neurorehabilitation, leading to effective and recreational therapies that are easily accessible to the population[11]. It allows improvements in affected upper limb functionality and a greater adherence to therapy by children and families[32][33][34].

    The International Classification of Functioning, Disability, and Health (ICF) provides a standard language and framework for the description of health and health-relate states[35]. The ICF emphasizes the importance of measuring or addressing an individual’s function, not only in terms of body structure and function, but also in terms of activities, participation, and environmental factors. Optimal outcome assessment tools should therefore consider the multidimensional nature of function as described by the ICF and measure these multiple facets[36][37]. There is currently a lack of information regarding the measurement tools used for the assessment of different affected upper limb aspects to increase the activity of children with OBP, since most tools assess the range of movement as Mallet scale or goniometric values, based on the reference levels of body structure and function of the ICF[38].

    Compared to conventional TM, virtual reality TM would be a therapeutic home supplement to increase independent bimanual tasks using grip on the affected upper limb and improve the quality of life of children diagnosed with upper BPO in the 6-12 year age range.

    The entry is from 10.3390/jcm9093021


    1. Zafeiriou, D.I.; Psychogiou, K. Obstetrical brachial plexus palsy. Pediatr. Neurol. 2008, 38, 235–242.
    2. Srofenyoh, E.K.; Seffah, J.D. Prenatal, labor and delivery characteristics of mothers with macrosomic babies. Int. J. Gynaecol. Obstet. 2006, 93, 49–50.
    3. Piasek, G.; Starzewski, J.; Chil, A.; Wrona-Cyranowska, A. Analysis of labour and perinatal complications in case of foetus weight over 4000 g. Wiad Lek. 2006, 59, 326–331.
    4. Gilbert, A. Long-term evaluation of brachial plexus surgery in obstetrical palsy. Hand Clin. 1995, 11, 583–594.
    5. Strömbeck, C. Long-term follow-up of children with obstetric brachial plexus palsy I: Functional aspects. Dev. Med. Child. Neurol. 2007, 49, 198–203.
    6. Galbiatti, J.A.; Cardoso, F.L.; Galbiatti, M.G.P.; Obstetric Paralysis: Who is to blame? A systematic literature review. Rev. Bras. Ortop. 2020, 55, 139–146, .
    7. Al-Quattan, M.M.; Clarke, H.M.; A historical note on the intermediate type of obstetrical brachial plexus palsy. J. Hand Surg. 1984, 19, 673, .
    8. Saleh M. Shenaq; Edward Berzin; Rita Lee; John P. Laurent; Rahul Nath; Maureen R. Nelson; Brachial Plexus Birth Injuries and Current Management. Clinics in Plastic Surgery 1998, 25, 527-536, 10.1016/s0094-1298(20)32445-7.
    9. Narakas, A.O. Injuries to the brachial plexus. In The Pediatric Upper Extremity: Diagnosis and Management; Bora, F.W., Jr., Ed.; W.B. Saunders: Philadelphia, PA, USA, 1986; pp. 247–258.
    10. Narakas, A.O. Obstetrical brachial plexus injuries. In The Paralysed Hand: The Hand and Upper Limb; Lamb, D.W., Ed.; Churchill Livingstone: Edinburgh, UK, 1987; Volume 2, pp. 116–135.
    11. Robert B. Gherman; Joseph G. Ouzounian; T.Murphy Goodwin; Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. American Journal of Obstetrics and Gynecology 1998, 178, 1126-1130, 10.1016/s0002-9378(98)70312-6.
    12. Bruce E. Kendall; Some directions in ecological theory.. Ecology 2015, 96, 3117-3125, 10.1890/14-2080.1.
    13. V. S. Ramachandran; Eric L. Altschuler; The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain 2009, 132, 1693-1710, 10.1093/brain/awp135.
    14. Holm Thieme; Jan Mehrholz; Marcus Pohl; Christian Dohle; Mirror therapy for improving motor function after stroke. Cochrane Database of Systematic Reviews 2010, 7, CD008449, 10.1002/14651858.cd008449.
    15. Marine Jequier Gygax; Patrick Schneider; Christopher John Newman; Mirror therapy in children with hemiplegia: a pilot study. Developmental Medicine & Child Neurology 2011, 53, 473-476, 10.1111/j.1469-8749.2011.03924.x.
    16. Sebastian Grunt; Christopher John Newman; Stefanie Saxer; Maja Steinlin; Christian Weisstanner; Alain Kaelin-Lang; The Mirror Illusion Increases Motor Cortex Excitability in Children With and Without Hemiparesis. Neurorehabilitation and Neural Repair 2016, 31, 280-289, 10.1177/1545968316680483.
    17. Giacomo Rizzolatti; Corrado Sinigaglia; The mirror mechanism: a basic principle of brain function. Nature Reviews Neuroscience 2016, 17, 757-765, 10.1038/nrn.2016.135.
    18. Giovanni Buccino; Ana Solodkin; Steven L. Small; Functions of the Mirror Neuron System: Implications for Neurorehabilitation. Cognitive And Behavioral Neurology 2006, 19, 55-63, 10.1097/00146965-200603000-00007.
    19. Valerie M. Pomeroy; Christopher A. Clark; J. Simon G. Miller; Jean-Claude Baron; Hugh S. Markus; Raymond C. Tallis; The Potential for Utilizing the “Mirror Neurone System” to Enhance Recovery of the Severely Affected Upper Limb Early after Stroke: A Review and Hypothesis. Neurorehabilitation and Neural Repair 2005, 19, 4-13, 10.1177/1545968304274351.
    20. Rizzolatti, G.; Fogassi, L.; Gallese, V. Neurophysiological mechanisms underlying the understanding and imitation of action. Nat. Rev. Neurosci. 2001, 2, 661–670.
    21. Kilner, J.M.; Paulignan, Y.; Blakemore, S.J. An interference effect of observed biological movement on action. Curr. Biol. 2003, 13, 522–525.
    22. Beatriz Calvo-Merino; Julie Grèzes; Daniel E. Glaser; Richard E. Passingham; Patrick Haggard; Seeing or Doing? Influence of Visual and Motor Familiarity in Action Observation. Current Biology 2006, 16, 1905-1910, 10.1016/j.cub.2006.07.065.
    23. Sgandurra, G.; Ferrari, A.; Cossu, G.; Guzzetta, A.; Fogassi, L.; Cioni, G. Randomized trial of observation and execution of upper extremity actions versus action alone in children with unilateral cerebral palsy. Neurorehabil. Neural Repair 2013, 27, 808–815.
    24. Buccino, G.; Molinaro, A.; Ambrosi, C.; Arisi, D.; Mascaro, L.; Pinardi, C.; Rossi, A.; Gasparotti, R.; Fazzi, E.; Galli, J. Action Observation Treatment Improves Upper Limb Motor Functions in Children with Cerebral Palsy: A Combined Clinical and Brain Imaging Study. Neural. Plast. 2018, 2018, 4843985.
    25. Nuara, A.; Avanzini, P.; Rizzolatti, G.; Fabbri-Destro, M. Efficacy of a home-based platform for child-to-child interaction on hand motor function in unilateral cerebral palsy. Dev. Med. Child Neurol. 2019, 61, 1314–1322.
    26. Jane Galvin; Rachael McDonald; Cathy Catroppa; Vicki A Anderson; Does intervention using virtual reality improve upper limb function in children with neurological impairment: A systematic review of the evidence. Brain Injury 2011, 25, 435-442, 10.3109/02699052.2011.558047.
    27. Sue Ann Sisto; Gail F. Forrest; Diana Glendinning; Virtual Reality Applications for Motor Rehabilitation After Stroke. Topics in Stroke Rehabilitation 2002, 8, 11-23, 10.1310/yabd-14ka-159p-mn6f.
    28. Jurgen Broeren; Ann Björkdahl; Ragnar Pascher; Martin Rydmark; Virtual Reality and Haptics as an Assessment Device in the Postacute Phase after Stroke. CyberPsychology & Behavior 2002, 5, 207-211, 10.1089/109493102760147196.
    29. J. H. Crosbie; S. Lennon; J. R. Basford; Professor S. M. McDonough; Virtual reality in stroke rehabilitation: Still more virtual than real. Disability and Rehabilitation 2007, 29, 1139-1146, 10.1080/09638280600960909.
    30. Ehud Arad; Derek Stephens; Christine G. Curtis; Howard M. Clarke; Botulinum Toxin for the Treatment of Motor Imbalance in Obstetrical Brachial Plexus Palsy. Plastic and Reconstructive Surgery 2013, 131, 1307-1315, 10.1097/prs.0b013e31828bd487.
    31. Shamekh El-Shamy; Rabab Alsharif; Effect of virtual reality versus conventional physiotherapy on upper extremity function in children with obstetric brachial plexus injury. Journal of musculoskeletal & neuronal interactions 1970, 17, 319-326, .
    32. Chen, Y.P.; Lee, S.Y.; Howard, A.M. Effect of virtual reality on upper extremity function in children with cerebral palsy: A meta-analysis. Pediatr. Phys. Ther. 2014, 26, 289–300.
    33. Olivieri, I.; Chiappedi, M.; Meriggi, P.; Mazzola, M.; Grandi, A.; Angelini, L. Rehabilitation of children with hemiparesis: A pilot study on the use of virtual reality. Biomed. Res. Int. 2013, 2013, 1–5.
    34. Kassee, C.; Hunt, C.; Holmes, M.W.R.; Lloyd, M. Home-based Nintendo Wii training to improve upper-limb function in children ages 7 to 12 with spastic hemiplegic cerebral palsy. J. Pediatr. Rehabil. Med. 2017, 10, 145–154.
    35. World Health Organization. International Classification of Functioning, Disability, and Health; World Health Organization: Geneva, Switzerland, 2001.
    36. Gilmore, R.; Sakzewski, L.; Boyd, R. Upper limb activity measures for 5- to 16-year-old children with congenital hemiplegia: A systematic review. Dev. Med. Child Neurol. 2010, 52, 14–21.
    37. Wagner, L.V.; Davids, J.R. Assessment tools and classification systems used for the upper extremity in children with cerebral palsy. Clin. Orthop. Relat. Res. 2012, 470, 1257–1271
    38. Rocío Palomo Carrión; Raquel Sánchez López; Fisioterapia aplicada en la extremidad superior a niños de 0 a 10 años con parálisis braquial obstétrica: revisión sistemática. Revista de Neurología 2020, 71, 1-10, 10.33588/rn.7101.2020029.