Short-term outcome of physiotherpy and surgical treatment of obstetrical brachial plexus palsy
Authors
- Krishna Priya DasDepartment of Orthopaedics, Bangabandhu Sheikh Mujib Medical University (currently Bangladesh Medical University), Dhaka, Bangladesh
- Rumpa Mani ChowdhuryDepartment of Neonatology, Bangabandhu Sheikh Mujib Medical University (currently Bangladesh Medical University), Dhaka, Bangladesh
- Sk. Murad AhmedDepartment of Orthopaedics, Bangabandhu Sheikh Mujib Medical University (currently Bangladesh Medical University), Dhaka, Bangladesh
- Md. MoniruzamanDepartment of Orthopaedics, Bangabandhu Sheikh Mujib Medical University (currently Bangladesh Medical University), Dhaka, Bangladesh
- Mohammod ShahidullahDepartment of Neonatology, Bangabandhu Sheikh Mujib Medical University (currently Bangladesh Medical University), Dhaka, Bangladesh
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Published by Bangabandhu Sheikh Mujib Medical University (currently Bangladesh Medical University).
Methods: This study was conducted in the Orthopaedic and Neonatology Department at Bangabandhu Sheikh Mujib Medical University. Infants with OBPP who presented within six months were included and initially treated with physiotherapy for up to six months. There were incomplete (neuropraxia and axonotmesis) and complete (neurotmesis) injuries. If biceps power was recovered of birth (≥M3), therapy was continued for up to 18 months. If there was no significant improvement (≤M2), surgery was performed. The final outcome was assessed after 18 months using the Mallet score, the Raimondi score, and the Medical Research Council muscle grading scale.
Results: Out of 200 OBPP cases, 90% were enrolled through the outpatient department. One-fourth were identified during the neonatal period. The majority (96%) were born via vaginal delivery, with shoulder dystocia occurring in 68% of cases. Instrumental deliveries resulted in more severe injuries. Females and right-sided involvement were predominant. The overall satisfactory result with physiotherapy was observed in 65%, cases, whereas after surgery, it improved to 80%. However, when considering the upper trunk only, it approached 85% with physiotherapy and 98% after surgery (Mallet score >15, Medical Research Council grade ≥ 4, Raimondi score ≥2). For lower trunk and panplexus cases, satisfactory outcomes following physiotherapy and surgery were 41%.
Conclusion: Treatment initiated within six months have ensured nearly full recovery of most upper trunk and incomplete OBPP cases, but outcomes of severely affected lower trunk and panpalsy cases was poor.
The physician first demonstrated physiotherapy to the parents, who were advised to perform the exercises regularly for a minimum of six months. The first group consists of passive, gentle, repeated, and systematic shoulder, elbow, wrist, and fingers mobilisation, irrespective of age and type of OBPP. Sessions lasting 10 to 15 minutes, conducted at least eight times per day, were encouraged. The second group of exercises, aimed at infants aged at least three months, includes engaging interactive activities with colourful toys that produced sounds and light balloons, designed to stimulate recovery through bimanual gripping. Furthermore, shoulder external rotation (airplane) splinting played an important role for those with developed shoulder adduction and internal rotation deformities. A wrist splint was recommended for those who exhibited wrist drop along with thumb adduction deformity. Those who showed satisfactory improvement in biceps function, as measured by the Medical Research Council (MRC) scale ≥ M3 within six months following physiotherapy, continued with the exercise programme for up to 18 months. If satisfactory improvement in biceps function was not achieved, appropriate investigations were undertaken, and a plan for surgical treatment was formulated [2, 3, 6].
Electrodiagnosis, which includes nerve conduction studies and electromyography, can provide valuable clinical information, although interpreting motor unit action potentials may prove challenging. Electrodiagnosis studies can address the following questions: What location and specific segment were involved? How extensive or severe was the condition (axonotmesis or neurotmesis), and was it preganglionic or postganglionic? Magnetic resonance imaging highly sensitive in detecting lesions of the peripheral nerves was done in severe cases only. MRN was localised the site and type of lesion eighter rapture of evolution of the roots. [4, 13]
Intra-plexus (primary) microsurgical procedures (Figure 1), such as neurolysis, excision of neuroma followed by nerve repair, nerve grafting, or neurotization (nerve transfer), were performed solely on those who had not recovered to a satisfactory level after 6 months of physiotherapy. Those who achieved satisfactory improvement in antigravity biceps power (≥M3) within 6 months but had some residual deformities continued with physiotherapy and were planned for deformity correction (secondary surgery) through soft tissue release with muscle transfer procedures after 18 months of age (Figure 2). Michelow et al. assigned the indication for primary microsurgical procedures if a score of less than 3.5 out of the highest possible score of 10 was recorded. A score between 0 and 2, where 0 denotes no function, 1 denotes partial function, and 2 denotes normal function, of the five motor functions (elbow flexion, wrist, finger, thumb extensions, and shoulder abduction) is assessed after three months of age. If the score exceeds 3.5, follow-up is recommended for up to 18 months; if any functional deficiencies are noted, secondary surgical procedures are advised to correct them. Conversely, a Mallet score of less than 13 out of 25 (five functions, each rated from one to five points, including shoulder abduction, external rotation, hand to mouth, hand to neck, and hand on spine) at three months of age also indicates the need for upper plexus surgery palsy [2, 3,7,14].

The follow-up schedule consisted of monthly visits for the first six months, followed by bi-monthly visits for a further six months, and finally, quarterly visits until 30 months. The minimum required follow-up was 18 months; however, a follow-up period of at least 36 months is necessary to properly evaluate complete panpalsy cases. Functional improvement was evaluated using different scales. Typically, upper plexus palsy cases were assessed by the Mallet score, which evaluates shoulder and elbow function. The components include global external rotation, abduction, hand-to-mouth, hand-to-neck, and hand-to-spine movements. The highest possible score is 25, with scores ranging from 14 to 25 considered satisfactory and scores from 0 to 13 deemed unsatisfactory. The Raimondi score is used to assess hand and wrist function, where scores of 0-1 are considered unsatisfactory, scores of 2-3 are viewed as satisfactory, and overall muscle strength was assessed using the MRC scale, where M≥3 was considered satisfactory and M≤2 is deemed unsatisfactory [2, 3,12,13].

Upper panel: Primary surgery of a 6 months old girl, a) extended left-upper obstetrical brachial plexus (C5,6,7), b) cables nerve grafting, c) ulnar nerve fascicle transfer to biceps br. of MCN, d) excellent recovery of 24 months follow up abduction and external rotation of shoulder.
Lower panel: Secondary surgery of a 18 months old girl, e) adduction and internal rotation deformity of shoulder, f) release of pectoralis major, g) release of LD and transfer to teres minor, h) excellent recovery of 6 months follow up.
The therapeutic approaches employed are grounded in the standard practices of the division under the lead author (KPD). However, the procedure, risks, and benefits were explained to the patient’s parents (or legal guardians), and written informed consent was obtained. Permission to disclose the patients’ photo for research and publication purposes was secured. They were assured that all data would remain confidential and not be disclosed except for the education of students of the orthopaedics courses. All participants were guaranteed the full right to decline the surgical interventions.
Data analysis was performed using SPSS version 26.0. The categorical variables (sex, parity of mother, delivery type, presentation, etc.) are presented as numbers (percentages), while numerical variables (age at presentation, birth weight, etc.) were expressed as mean (standard deviation).
Background characteristics | Number (%) |
Age at presentation (weeks)a | 14.3 (9.2) |
Gestational age at birth (weeks)a | 37.5 (2.8) |
Birth weight (grams)a | 2,975.0 (825.0) |
Sex |
|
Male | 82 (41) |
Female | 118 (59) |
Affected side |
|
Right | 140 (70) |
Left | 54 (27) |
Bilateral | 6 (3) |
Delivery type |
|
Normal vaginal delivery | 152 (76) |
Instrumental delivery | 40 (20) |
Cesarean section | 8 (4) |
Place of delivery |
|
Home delivery by traditional birth attendant | 30 (15) |
Hospital delivery by midwife | 120 (60) |
Hospital delivery by doctor | 50 (25) |
Prolonged labor | 136 (68) |
Presentation |
|
Cephalic | 144 (72) |
Breech | 40 (20) |
Transverse | 16 (8) |
Shoulder dystocia | 136 (68) |
Maternal diabetes | 40 (20) |
Maternal age (years)a | 27.5 (6.8) |
Parity of mother |
|
Primipara | 156 (78) |
Multipara | 156 (78) |
aMean (standard deviation), all others are n (%) |
Background characteristics | Number (%) |
Age at presentation (weeks)a | 14.3 (9.2) |
Gestational age at birth (weeks)a | 37.5 (2.8) |
Birth weight (grams)a | 2,975.0 (825.0) |
Sex |
|
Male | 82 (41) |
Female | 118 (59) |
Affected side |
|
Right | 140 (70) |
Left | 54 (27) |
Bilateral | 6 (3) |
Delivery type |
|
Normal vaginal delivery | 152 (76) |
Instrumental delivery | 40 (20) |
Cesarean section | 8 (4) |
Place of delivery |
|
Home delivery by traditional birth attendant | 30 (15) |
Hospital delivery by midwife | 120 (60) |
Hospital delivery by doctor | 50 (25) |
Prolonged labor | 136 (68) |
Presentation |
|
Cephalic | 144 (72) |
Breech | 40 (20) |
Transverse | 16 (8) |
Shoulder dystocia | 136 (68) |
Maternal diabetes | 40 (20) |
Maternal age (years)a | 27.5 (6.8) |
Parity of mother |
|
Primipara | 156 (78) |
Multipara | 156 (78) |
aMean (standard deviation), all others are n (%) |
Mean escape latency of acquisition day | Groups | ||||
NC | SC | ColC | Pre-SwE Exp | Post-SwE Exp | |
Days |
|
|
|
|
|
1st | 26.2 (2.3) | 30.6 (2.4) | 60.0 (0.0)b | 43.2 (1.8)b | 43.8 (1.6)b |
2nd | 22.6 (1.0) | 25.4 (0.6) | 58.9 (0.5)b | 38.6 (2.0)b | 40.5 (1.2)b |
3rd | 14.5 (1.8) | 18.9 (0.4) | 56.5 (1.2)b | 34.2 (1.9)b | 33.8 (1.0)b |
4th | 13.1 (1.7) | 17.5 (0.8) | 53.9 (0.7)b | 35.0 (1.6)b | 34.9 (1.6)b |
5th | 13.0 (1.2) | 15.9 (0.7) | 51.7 (2.0)b | 25.9 (0.7)b | 27.7 (0.9)b |
6th | 12.2 (1.0) | 13.3 (0.4) | 49.5 (2.0)b | 16.8 (1.1)b | 16.8 (0.8)b |
Average of acquisition days | |||||
5th and 6th | 12.6 (0.2) | 14.6 (0.8) | 50.6 (0.7)b | 20.4 (2.1)a | 22.4 (3.2)a |
NC indicates normal control; SC, Sham control; ColC, colchicine control; SwE, swimming exercise exposure. aP <0.05; bP <0.01. |
Categories | Number (%) |
Sex |
|
Male | 36 (60.0) |
Female | 24 (40.0) |
Age in yearsa | 8.8 (4.2) |
Education |
|
Pre-school | 20 (33.3) |
Elementary school | 24 (40.0) |
Junior high school | 16 (26.7) |
Cancer diagnoses |
|
Acute lymphoblastic leukemia | 33 (55) |
Retinoblastoma | 5 (8.3) |
Acute myeloid leukemia | 4 (6.7) |
Non-Hodgkins lymphoma | 4 (6.7) |
Osteosarcoma | 3 (5) |
Hepatoblastoma | 2 (3.3) |
Lymphoma | 2 (3.3) |
Neuroblastoma | 2 (3.3) |
Medulloblastoma | 1 (1.7) |
Neurofibroma | 1 (1.7) |
Ovarian tumour | 1 (1.7) |
Pancreatic cancer | 1 (1.7) |
Rhabdomyosarcoma | 1 (1.7) |
aMean (standard deviation) |
Narakas classification | Total 200 (100%) | Grade 1 72 (36%) | Grade 2 64 (32%) | Grade 3 50 (25%) | Grade 4 14 (7%) |
Complete recoverya | 107 (54) | 60 (83) | 40 (63) | 7 (14) | - |
Near complete functional recovery but partial deformitya | 22 (11) | 5 (7) | 10 (16) | 6 (12) | 1 (7) |
Partial recovery with gross functional defect and deformity | 31 (16) | 7 (10) | 13 (20) | 10 (20) | 1 (7) |
No significant improvement | 40 (20) | - | 1 (1.5) | 27 (54) | 12 (86) |
aSatisfactory recovery bGrade 1, C5, 6, 7 improvement; Grade 2, C5, 6, 7 improvement; Grade 3, panpalsy C5, 6, 7, 8, 9, Grade 4, panpalsy with Hornon’s syndrome. |
Narakas classification | Total 200 (100%) | Grade-1 72 (36%) | Grade-2 64 (32%) | Grade-3 50 (25%) | Grade-4 14 (7%) |
Complete recoverya | 107 (54) | 60 (83) | 40 (63) | 7 (14) | - |
Near complete functional recovery but partial deformitya | 22 (11) | 5 (7) | 10 (16) | 6 (12) | 1 (7) |
Partial recovery with gross functional defect and deformity | 31 (16) | 7 (10) | 13 (20) | 10 (20) | 1 (7) |
No significant improvement | 40 (20) | - | 1 (1.5) | 27 (54) | 12 (86) |
aSatisfactory recovery bGrade 1, C5, 6, 7 improvement; Grade 2, C5, 6, 7 improvement; Grade 3, panpalsy C5, 6, 7,8,9, Grade 4, panpalsy with Hornon’s syndrome. |
Variables in probe trial day | Groups | ||||
NC | SC | ColC | Pre-SwE Exp | Post-SwE Exp | |
Target crossings | 8.0 (0.3) | 7.3 (0.3) | 1.7 (0.2)a | 6.0 (0.3)a | 5.8 (0.4)a |
Time spent in target | 18.0 (0.4) | 16.2 (0.7) | 5.8 (0.8)a | 15.3 (0.7)a | 15.2 (0.9)a |
NC indicates normal control; SC, Sham control; ColC, colchicine control; SwE, swimming exercise exposure. aP <0.01. |
Pain level | Number (%) | P | ||
Pre | Post 1 | Post 2 | ||
Mean (SD)a pain score | 4.7 (1.9) | 2.7 (1.6) | 0.8 (1.1) | <0.001 |
Pain categories | ||||
No pain (0) | - | 1 (1.7) | 31 (51.7) | <0.001 |
Mild pain (1-3) | 15 (25.0) | 43 (70.0) | 27 (45.0) | |
Moderete pain (4-6) | 37 (61.7) | 15 (25.0) | 2 (3.3) | |
Severe pain (7-10) | 8 (13.3) | 2 (3.3) | - | |
aPain scores according to the visual analogue scale ranging from 0 to 10; SD indicates standard deviation |
Surgeries | Number (%) | Satisfactory outcomes n (%) |
Primary surgery (n=24) |
|
|
Upper plexus | 6 (25) | 5 (83) |
Pan-palsy | 18 (75) | 6 (33) |
All | 24 (100) | 11 (46) |
Secondary Surgery (n=26) |
|
|
Shoulder deformity | 15 (58) | 13 (87) |
Wrist and forearm deformity | 11 (42) | 6 (54) |
All | 26 (100) | 19 (73) |
Primary and secondary surgery | 50 (100) | 30 (60) |
Mallet score 14 to 25 or Raimondi score 2-3 or Medical Research grading >3 to 5. |
Narakas classification | Total 200 (100%) | Grade-1 72 (36%) | Grade-2 64 (32%) | Grade-3 50 (25%) | Grade-4 14 (7%) |
Complete recoverya | 107 (54) | 60 (83) | 40 (63) | 7 (14) | - |
Near complete functional recovery but partial deformitya | 22 (11) | 5 (7) | 10 (16) | 6 (12) | 1 (7) |
Partial recovery with gross functional defect and deformity | 31 (16) | 7 (10) | 13 (20) | 10 (20) | 1 (7) |
No significant improvement | 40 (20) | - | 1 (1.5) | 27 (54) | 12 (86) |
aSatisfactory recovery bGrade 1, C5, 6, 7 improvement; Grade 2, C5, 6, 7 improvement; Grade 3, panpalsy C5, 6, 7,8,9, Grade 4, panpalsy with Hornon’s syndrome. |
Trials | Groups | ||||
NC | SC | ColC | Pre-SwE Exp | Post-SwE Exp | |
1 | 20.8 (0.6) | 22.1 (1.8) | 41.1 (1.3)b | 31.9 (1.9)b | 32.9 (1.8)a, b |
2 | 10.9 (0.6) | 14.9 (1.7) | 37.4 (1.1)b | 24.9 (2.0)b | 26.8 (2.5)b |
3 | 8.4 (0.5) | 9.9 (2.0) | 32.8 (1.2)b | 22.0 (1.4)b | 21.0 (1.4)b |
4 | 7.8 (0.5) | 10.4 (1.3) | 27.6(1.1)b | 12.8 (1.2)b | 13.0 (1.4)b |
Savings (%)c | 47.7 (3.0) | 33.0 (3.0) | 10.0 (0.9)b | 23.6 (2.7)b | 18.9 (5.3)b |
NC indicates normal control; SC, Sham control; ColC, colchicine control; SwE, swimming exercise exposure. aP <0.05; bP <0.01. cThe difference in latency scores between trials 1 and 2, expressed as the percentage of savings increased from trial 1 to trial 2 |

