Publications

Case report, traumatic brachial plexus lesion

A six year old girl with a traumatic brachial plexus lesion

by Mrs. L F. van Wermeskerken-Dutry van Haeften and Mrs. W.M. M. van Gunsteren- Woltjer
Published in the Dutch periodical Physiotherapy, 10-1980, page 323

 

Summary

A general exercise programme according to the Bugnet posture resistance therapy is - especially in the beginning, when the muscles have no strength - an important factor in the whole treatment. The programme meets various problems that occur in the supervision of the recovery of a patient with a brachial plexus lesion.
The essential functions of the hand are centrally activated during the total static exercises from the onset. The exercises with movement are applied firstly after some muscle strength had returned to the paretic body part.  The patient has developed favourably in all respects despite her handicap and can participate fully in a normal child's life (see fig. 8).

 

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picture Summer 1978

 

 A practical case, i.e. a six year old patient with a Brachial Plexus lesion provided the details for this article. The article describes the general remedial therapy treatment according to the Bugnet posture resistance therapy. This method makes use of total static exercises in which the paretic muscle groups are trained in a stabilising function and are stimulated to maximum action by the application of resistance and muscular manipulations.

The paresis in this patient began in 1976 when the girl fell through a glass door. The right armpit was cut through to the bone. The Brachial plexus nerves were cut through at the fasciculi ('cords') (see fig. 1), as well as the A. Axillaris, the large arteries, M. Pectoralis and M. Latissimus dorsi. Emergency treatment in hospital followed and an operation took place to stitch up the cut arteries, nerves, muscles, subcutaneous tissue and skin.

When a patient with this sort of trauma leaves hospital and continues his daily life, he must be supervised for maximum recovery in conjunction with various disciplines. This provides the physiotherapists with many varied problems. A provisional diagnosis is made based on the position of the cut nerve to enable the possible consequences of the lesion to be predicted (com. fig. 1). Consultation of innervation schemes (e.g. Riddoch G. et al. -Aids to the investigation of peripheral nerve injuries, 1951) shows where the first signs of recovery can be expected and where most problems will occur. The hand which lies the most distal, and which must wait longest for recovery of the innervation, is always the most threatened area. A total motoric­ and sensory breakdown exists in their ­respective treatment areas distal from the cut nerves.

 

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fig. 1 Plexus Brachialis (Kendal H.O en P.P. - Muscles, Testing and Function 1971)

 

The dangers this usually brings are:

  • formation of contractions of the scapula elevator
  • luxation of the shoulder joint (due to the weight of the arm)
  • formation of scoliose (especially in child­ren)
  • slower bone growth (especially in children) and possible disruption to family life (especially in children)
  • and the psychic problems of the handicap

The supervision of a patient with a lesion of the Brachila Plexus consists mainly of the following elemen­ts:

a.      regular check-ups by the GP, neurologist, physiotherapist and psycho­logist;

b.      drawing up and carrying out a da­ily exercise programme;

c.      electro-stimulation;

d.      protecting the joints (sling, night splints, etc.);

e.      technical information from the A.V.G. (Algemene Voorlichting Ge­handicapten [General Information for the Handicapped) to facilitate independence in daily life­;

f.        gymnastic exercises that help the reco­very progress, with rola bola, springs, games, as desired;

g.      myo-feedback exercises when coordination disorders occur.

This article is limited to drawing up­ and carrying out the daily exercise­ programme.

 

Theoretical drawing up of the exercise programme

The main consideration when drawing up the daily exercise plan is to practice various functions of the hand from the onset and to make the connection­, from that starting point, with the corrected spinal column and shoulder girdle, in total muscle training exercises. The programme must be exact and provide maximum training and stimulation in a short time.

 

Some functions of the hand

The following important functions of the hand are trained from the onset:

  • cylinder grip (prehensive grip), in middle position, supination and pronation;
  • lumbricales grip (static pinch), round a small block;
  • big grip (ball grip), around a larger block;
  • cylinder grip (prehensive grip), in middle position, supination and pronation;
  • support function (push-ups), sideways and forwards;
  • maximum abduction and anteflexion of arm, active and in supporting function, so that permission for abduction is given.

Relief of problems

A general exercise programme ­according to the Bugnet posture resistance therapy meets various pro­blems simultaneously:

 

  • Stimulating the motor system and bone growth
    The paretic hand (that has an unfavourable­ prognosis) receives most attention from the onset. The pri­mary reflexive grip and support func­tions are constantly called upon ­ to stimulate both the reflexive motoric reactions and bone growth.
  • Maximum training.
    A maximum cocontraction is called upon­ as a reaction to the fixed paretic hand, arm and shoulder giving maximum resistance outwardly, in a starting position with closed chains. In the total exercise an 'overflow of excitation' in this fashion promotes maxi­mum stimulation.
  • Combating contractions
     The formation of contractions is combated in a starting position with spinal column­, shoulder girdle, arm and hand in corrected (or over-corrected) position and kept up during the ­exercises.
  • Intensifying the motoric reaction
    The sensibility­ is called upon by means of muscu­lar manipulations on the paretic muscle groups to intensify the motoric reac­tion at the place.
  • Avoids long hospitalisation
    Children can be exercised at home by parents or housemates because the exercise programme is easily le­arnt and carried out under the supervision­ of a physiotherapist.
  • Undemanding
    The exercises are more or less automatic and for this reason are not psy­chologically demanding. The motori­c reactions come about for a large part in a reflexive fashion.

 

Carrying out the exercise programme

The general exercise programme for the six year old girl with a Brachial Plexus lesion on her right side was ba­sed on the Bugnet posture resistance manual by W. van Gunsteren et al. (19783). The program­me consists of exercises borrowed from Chapter I of the manual. These exercises are described briefly below, with reference­ (in italics) to the full description­ in the manual:

 

  • Exercise with cylinder grip, in middle po­sition and in supination (not shown, comp. manual I. U).
  • Exercise with cylinder grip in pronation, see fig 2 (comp. 1.12).
  • Exercise with lumbricales grip, see fig. 3 (comp. 1.13).
  • Exercise with big grip in pushing pattern (not shown, comp. 1.14).
  • Exercise with finger extension, pushing (not shown, comp. 1.15).
  • Exercise with cylinder grip with brachia­tion, see fig. 4, (comp. 1.6, 1.10).

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The supporting exercises, as well as maximum abduction and anteflexion in the arm, can receive more attention as the recovery progresses and strength returns to the upper arm and shoulder:

  • Sideways supporting exercise sideways, see fig. 5 (comp. 1.4)
  • Forward supporting exercise forwards, see fig. 6 (comp. I.8a).
  • Exercise with maximum abduction and anteflexion of the arm, active, see fig. 7 (comp. A.15).
  • Exercise with maximum abduction and anteflexion of the arm against resistance (not shown, comp. 1.3, 1.8b).

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