Rehabilitation of a Child with Neonatal Brachial Plexus Palsy PDF

children Case Report Rehabilitation of a Child with Neonatal Brachial Plexus Palsy: Case Report Described by Parents Fátima Frade 1,2 , Lurdes Neves 3 , Fátima Florindo-Silva 4,5 , Juan Gómez-Salgado 6,7, * , Lia Jacobsohn 4,8 and João Frade 9,10 1 Depar...

children Case Report Rehabilitation of a Child with Neonatal Brachial Plexus Palsy: Case Report Described by Parents Fátima Frade 1,2 , Lurdes Neves 3 , Fátima Florindo-Silva 4,5 , Juan Gómez-Salgado 6,7, * , Lia Jacobsohn 4,8 and João Frade 9,10 1 Departamento de Enfermagem da Criança e do Jovem, Escola Superior de Enfermagem de Lisboa, Avenida Professor Egas Moniz, 1600-190 Lisboa, Portugal 2 Centro de Administração e Políticas Públicas (CAPP), Instituto Superior de Ciências Sociais e Políticas da Universidade de Lisboa, Rua Almerindo Lessa, 1300-663 Lisbon, Portugal 3 Escolher Brincar Terapia Ocupacional, Rua Professor Barbosa Soeiro 6, 4º Dto, 1600-598 Lisboa, Portugal 4 Physiotherapy and Osteopathy Departments, Atlântica Health School, Universidade Atlantica, 2730-036 Barcarena, Portugal 5 Serviço de Medicina Física e Reabilitação, Hospital Dona Estefânia-Centro Hospitalar Universitário Lisboa Central, 1169-045 Lisboa, Portugal 6 Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, 21007 Huelva, Spain 7 Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil 092301, Ecuador 8 Centro de Medicina de Reabilitação do Alcoitão, 2649-506 Alcabideche, Portugal 9 Centre for Innovative Care and Health Technology (ciTechcare), Escola Superior de Saúde, Instituto Politécnico de Leiria, 2411-901 Leiria, Portugal 10 Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, 4099-002 Porto, Portugal * Correspondence: [email protected]; Tel.: +34-959219700 Abstract: This paper presents a case report of a child with Neonatal Brachial Plexus Palsy on the right Citation: Frade, F.; Neves, L.; arm, with C5, C6, and C7 nerve injuries. The symptoms presented at birth and at the time of diagnosis Florindo-Silva, F.; Gómez-Salgado, J.; were absence of movement in the right arm but with mobility of the fingers; internal rotation of the Jacobsohn, L.; Frade, J. Rehabilitation injured limb with elbow extension; active flexion of the wrist and fingers; and ulnar deviation of the of a Child with Neonatal Brachial hand. The rehabilitation plan followed the conservative approach and included different intervention Plexus Palsy: Case Report Described strategies (passive and active mobilisation, kinesio tape, use of splints, bimanual stimulation, etc.) by Parents. Children 2022, 9, 1298. carried out by the occupational therapist and the physical therapist. The rehabilitation allowed the https://doi.org/10.3390/ children9091298 child to have a functional limb for daily activities, with bimanual motor integration and coordination; passive and active range of motion in the different joints except for pronation, sensibility, and Academic Editors: Shashank Ghai maintained strength. In conclusion, it can be said that this case report describes a set of rehabilitation and Andrea Martinuzzi strategies that were used in the conservative treatment of a child with NBPP and the functional gains Received: 27 June 2022 they allowed. Early intervention, parental involvement in the rehabilitation process, and continuous Accepted: 22 August 2022 follow-up of the child favoured the prognosis and allowed the prevention of functional sequelae of Published: 26 August 2022 the limb. Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in Keywords: brachial plexus palsy; neonatal brachial plexus palsy; neonatal management; rehabilitation; published maps and institutional affil- physical therapy; occupational therapy; case report with parents iations. 1. Introduction Copyright: © 2022 by the authors. Neonatal Brachial Plexus Palsy (NBPP) is a total or partial peripheral nerve injury Licensee MDPI, Basel, Switzerland. which may affect C5–T1 cervical and thoracic roots, and which occurs during birth [1,2]. This article is an open access article The injury occurs when there is stretching or rupture of myelin membranes or nerve distributed under the terms and trunk fibres or root avulsion. It can be classified according to the affected nerve com- conditions of the Creative Commons plex, the degree of severity, and functionality. There is an upper trunk injury when the Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ affected nerves are C5 and C6; a middle trunk injury when the affected nerve is C7; a 4.0/). lower trunk injury when the affected nerves are C8 and T1; and a complete injury when Children 2022, 9, 1298. https://doi.org/10.3390/children9091298 https://www.mdpi.com/journal/children Children 2022, 9, 1298 2 of 16 the affected nerves are C5–T1. The severity of the nerve injury is classified as avulsion injury when the nerve is torn; as neurotmesis injury when there is complete disruption of the axon and the connective tissue of the nerve; as axonotmesis injury when there is anatomical interruption of the axon, but no involvement of the connective tissue and nerve myelin; and finally, stretching of the nerve without interruption, which leads to a momentary blockage of the nerve–axon connection and recovers spontaneously. In the classification according to limb function, the NBPP lesion may be called Erb–Duchene syndrome or upper brachial plexus palsy (C5-C6), in which case shoulder abduction, shoul- der external rotation, and elbow flexion are impaired, while hand function is maintained; Dejerine–Klumpke syndrome or lower brachial plexus palsy (C7-C8-T1), which affects hand and wrist function; and complete brachial plexus palsy (C5-C6-C7-T1), which compromises complete arm function. In the latter case, if associated with a sympathetic nerve injury, it is called Horner’s syndrome (C8-T1-T2), with the child presenting ptosis, miosis, and anhidrosis on the eye of the affected side [3–6]. NBPP often leads to dysfunction of the affected upper limb, which may be related to the motor and sensory functions of the child’s arm and may include loss of passive and active range of motion, sensory and muscle strength deficits, retractions, muscle contractures, and/or deformities and functional deficits. Treatment options for NBPP are (1) conservative treatment, which includes intensive physical therapy and occupational therapy using techniques such as joint mobilisation, neurosensory motor stimulation, kinesio tape, electrostimulation, splint immobilisation, and constraint-induced movement therapy, among others, always including working in collaboration with families by teaching and training the family for continued intervention in a home context and medical intervention with botulinum toxin injection; and (2) non- conservative or surgical treatment, which may include primary and secondary surgeries. Primary surgeries are performed on children who have no spontaneous rehabilitation in the first three months of life, and secondary surgeries are performed on children who have significant functional limitations or functional deficits. NBPP is complex and recovery patterns are not yet fully understood or predictable, so decisions about the best treatment remain a challenge. Guidelines for the management of NBPP recommend (1) physical observation of the newborn with arm asymmetry or risk factors; (2) early referral to a multidisciplinary centre during the first month of age; (3) knowledge of pregnancy/delivery history and physical examination of the newborn at birth; (4) follow-up in multidisciplinary centres with therapists and neurosurgeons with expertise in NBPP; (5) physical therapy guided by a multidisciplinary team; (6) indication for nerve surgery if there is nerve avulsion or there are other surgical criteria resulting from the NBPP specialist team; and (7) data that should include Narakas classification, limb length, Active Movement Scale (AMS), and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery [6,8]. Studies have shown the effectiveness of using strategies such as Armeo robotic therapy, virtual reality, and plyometric training in the rehabilitation of children with Erb’s palsy, which can complement conventional therapy [9–11]. This case report describes a set of strategies that were used in the rehabilitation of a child with NBPP, the stages in the child’s development at which they were used, and the purpose of using these strategies. The case of a child with the right arm affected by NBPP, with damage to the C5, C6 and C7 nerves, who presented in the first days of life with absence of movement in the right arm, internal rotation of the injured limb with elbow extension, active flexion of the wrist and fingers, and ulnar deviation of the hand is reported here. She underwent an intensive early rehabilitation process with conservative treatment, physical therapy, and occupational therapy. In the rehabilitation of this girl, different intervention strategies were used (passive and active mobilisation, neurosensory motor stimulation, kinesio tape, use of splints, Children 2022, 9, 1298 3 of 16 constraint-induced movement therapy of the healthy limb, bimanual stimulation, bo- tulinum toxin, etc.). This rehabilitation process allowed functional and sensory recovery, without resorting to the compensations typical of this type of condition (bugle sign and difficulty in elbow flexion), the integration of the upper limb in age-appropriate movements and activities, and the prevention of musculoskeletal deformities. This work is relevant because it describes a set of strategies that were used in the conservative treatment for the rehabilitation of a child with NBPP. It highlights the ade- quacy of the strategies to the child’s development and the appearance of functions in the arm affected by the injury, as well as the functional gains that the child acquired in this rehabilitation process. It also highlights the importance of parental involvement in the rehabilitation process of the child with NBPP and the continued follow-up of the child. This case study is organised according to the Case Reports Guidelines (CARE) fol- lowing twelve steps: Title; Keywords; Abstract, Introduction, Patient Information; Clinical Finding; Chronology; Diagnostic Assessment; Therapeutic Intervention; Follow-Up and Outcomes; Discussion; and Patient Perspective. The information contained in this work was reported by the parents and validated by the therapists accompanying the child. 2. Patient Information This is the case of a Portuguese girl, Caucasian, currently 5 years old, with the right arm affected by NBPP. She was born on 10 March 2017 at 40 weeks + 3 days by forceps delivery, where there was shoulder dystocia. Good adaptation to extrauterine life, APGAR at birth 8 (1’), 9 (5’), and 10 (10’), weighing 4330 kg. After birth, she presented paralysis of the right upper limb with no movement in the arm and forearm, some mobility in the fingers, and no sensory response in the entire limb. There was no clavicle fracture. She developed neonatal jaundice on the second day of life and received phototherapy for 3 days, which was effective. Pregnancy had been monitored, with some complications. The first trimester combined screening result showed a risk for trisomy 21. The amniocentesis was negative. In the first trimester, the pregnant woman had a slight placental abruption that reverted with rest, and at the end of pregnancy, she developed hepatic cholestasis. The mother had no history of diabetes. 3. Clinical Findings Upon physical examination after birth, the child had the right upper limb along the body in internal rotation and with the elbow extended, the hand with active flexion of the wrist and in ulnar deviation, and the fingers flexed. In the evaluation of primitive reflexes, the asymmetric moro reflex and the asymmetric cervical tonic reflex were absent, and there was no response to tactile information. She was diagnosed in the maternity ward with Erb–Duchene Palsy or Right Upper Brachial Plexus Palsy (C5-C6) and was then referred for physical medicine and rehabilitation. Recovery of function of the affected limb was monitored over time, essentially through physical observation (physical examination), at key moments, which predicted the evolu- tion and prognosis of NBPP recovery. Physical assessment, which included observation of joint amplitude, assessment of muscle strength, posture and movement patterns, symmetry and alignment, muscle com-pressions, contractures and deformities, shoulder girdle stability and background movements of posture and global motor coordination (rotation, dissociation of movements, etc.) was performed. Sensory assessment was carried out by observing tactile, proprioceptive, vestibular and visual sensations, bilateral motor integration, and bilateral motor coordination. 4. Timeline Follow-up of the child presented chronologically: Children 2022, 9, 1298 4 of 16 10 March 2017 (aged 1 day). Diagnosis of NBPP (Erb–Duchene Palsy or Right Upper Brachial Plexus Palsy (C5-C6)) was made by the paediatrician from the maternity area. 20 March 2017 (aged 10 days). Physiatry consultation in the physical medicine and rehabilitation service, which prescribed intensive physical therapy and occupational ther- apy. The assessment by the physiatrist was carried out very closely during the physical therapy or occupational therapy session; whenever there was any significant recovery, the therapists asked the physiatrist to observe the child during the session. Consultations were formally held every 3 months (at 3, 6, 9, 12, 15, 18 months), from 18 months onwards, which was when intensive care ended, and every 6 months, which are still maintained. From March 2017 to September 2018 (0 to 18 months). Start of physical therapy three times a week and occupational therapy twice a week. End of March 2017 (First month of life). Plastic and reconstructive surgery consultation, the aim of which was to assess the need for surgical intervention for reconstruction of the affected nerves. Surgical evaluation was performed in the first month of life (26 March 2017), and then every 3 months until 12 months of age. After this age, she was evaluated every 6 months and after two years, annually. By June 2017 (3 months). The child was examined by the physiatrist and surgeon to check whether she had elbow flexion against gravity. At three months, the child did not have elbow flexion against gravity, but there was recovery in relation to shoulder extension and elbow flexion in favour of gravity, so it was decided to wait until 6 months to decide on the need for surgical intervention; electro-stimulation (16 Hz, 200 Us, 20 min a day on the biceps muscle) was prescribed by the physiatrist. Electromyography was performed to study the motor potential of the right ulnar nerve for a possible transfer of the ulnar nerve to the biceps brachii muscle. By July 2017 (4.5 months). Elbow flexion against gravity appeared. By September 2017 (6 months). Follow-up of plastic and reconstructive surgery deemed that surgical intervention was not considered necessary. Occupational therapy and physical therapy were maintained, and one-to-one hydrotherapy commenced with a specialist therapist once a week. Magnetic Resonance Imaging (MRI) of the right upper limb was performed for staging and exploration of shoulder function. By December 2017 (9 months). At the plastic and reconstructive surgery consultation, it was noted that the child was progressing well, with normal biceps function, but with a slight external rotation deficit, so botulinum toxin in the subscapularis muscle was proposed to the physiatrist, who decided to wait until 12 months. By April 2018 (13 months). With deficit in external rotation and supination, the patient underwent botulinum toxin injection in the subscapularis and teres major muscles and the pronator teres, and weekly intensive therapies were maintained (3 days of physical therapy and 2 days of occupational therapy), also adding electrostimulation 16 Hz, 200 Us, 20 min a day in the supinator and extensor muscles. By June 2018 (15 months). External rotation and supination appeared. By September 2018 (18 months). Plastic and Reconstructive Surgery consultation: surgery did not actively assess the limits of external rotation and supination, but passively, there did not seem to be a deficit that justified subscapularis release by surgery. Intensive therapy was discontinued, and physical activities (swimming and ballet) were initiated to allow maximum development of the motor skills. By March 2019 (2 years). Physical medicine and rehabilitation consultation: physical activity was recommended, and no indication for surgery was made in the plastic and reconstructive surgery consultation. By March 2020 (3 years). Due to the COVID-19 pandemic, some activities were sus- pended, such as swimming and ballet (as the institution did not guarantee safety conditions). The lack of physical activity and the lack of parental time to accompany her in activities at home (due to the birth of her brother) led to the appearance of patterns/compensations and difficulty in performing full pronation, and when not in use, the arm remained in the supine position. Children 2022, 9, 1298 5 of 16 To promote pronation, kinesio tape was used, as well as activities such as wheelbarrow, play dough, puzzles, etc. At the plastic and reconstructive surgery consultation, the accompanying physician considered that, given the child’s favourable evolution, the criteria for nerve surgery were not met. By September 2021 (4 years). MRI of the right shoulder joint was performed to assess the need for referral to paediatric orthopaedics and the eventual need for orthopaedic surgery. By October 2021 (4 years). In the physical medicine and rehabilitation consultation, the physiatrist discarded the need for referral to orthopaedics at this stage. At the plastic and reconstructive surgery consultation, nerve surgery was not considered necessary. The MRI of the right shoulder did not reveal significant changes, so annual monitoring by the plastic and reconstructive surgery consultation was maintained. As for the child’s growth and development, she has evolved in a healthy manner. 5. Diagnostic Assessment The diagnosis and staging of NBPP was essentially made through physical observation, considering the evolution and/or recovery of motor and sensory function. However, at key moments (3 months and 6 months), it was necessary to resort to diagnostic tests to decide on the most appropriate therapeutic option. Thus, at 3 months, an electromyogram (EMG) was performed, where the nerve con- duction velocity of the right ulnar nerve was studied, showing a good potential amplitude. The EMG report revealed a moderate neurogenic tracing of the deltoids and biceps brachii, more impoverished in the arm and axonal lesion of the C5-C6 roots (upper primary trunk) with reinnervation, but with evident loss of motor units in the cutaneous muscle territory. Motor potential of the ulnar nerve with acceptable amplitude was observed, with low sensory potential. The electromyogram was performed to assess the ulnar nerve potential, since if there was no elbow flexion, one of the surgeries that could be performed was the transfer of the ulnar nerve to the nerve of the biceps muscle. At 6 months, an MRI of the right upper limb was performed, which revealed, at the level of the brachial plexus, traumatic thickening/neuroma/meningocele of the C6-C7- C8-T1 roots. Signal alterations persisted until the formation of the distal trunks, dividing the nerve endings differently. As for the muscular apparatus, the right shoulder girdle, in relation to the left, did not show atrophy or significant asymmetry of the muscular planes. Regarding the osteoarticular apparatus, humeral glenoid showed retroversion with respect to the right glenoid (right glenoid—20 degrees; left glenoid—11 degrees). The hyposignal alteration of the posterior margin of the cartilaginous glenoid reflected incipient dysplasia. The purpose of the MRI performed at 6 months was to check for alterations in the shoulder girdle joint (e.g., glenohumeral subluxation), as this sequela can compromise the entire function of the arm and early identification can prevent its recurrence. At 4 years of age, an MRI of the right shoulder was performed in which there was a slight superior subluxation and a right posterior glenohumeral subluxation; morphology of the glenoid cavity relatively was maintained, with only a discrete flattening, but without signs of manifest dysplasia; right humeral head had preserved morphology; and the muscles of the shoulder girdle had reasonable volume, with the signal maintained except for the impossibility of comparison with the contralateral arm. No joint effusion was observed. This MRI was performed in order to assess the function of the shoulder girdle and prevent the sequelae. Imaging tests (MRI) were performed under sedation. The electromyogram was per- formed without sedation, with a needle electrode, as the child had decreased sensitivity in the injured arm, experienced no discomfort, and remained calm throughout the procedure. The parents were a little anxious about the performance of these invasive diagnostic tests for the child.  in in the the injured injured arm, arm, experienced experienced no no discomfort, discomfort, and and remained remained calm calm throughout throughout the the proce- proce dure. dure. The The parents parents were were aa little little anxious anxious about about the the performance performance of of these these invasive invasive diagnostic diagnostic tests for the child. tests for the child. Children 2022, 9, 1298 6 of 16 6. 6. Therapeutic Therapeutic Interventions Interventions Interventions Interventions for for recovery recovery from from NBPPNBPP were were incorporated incorporated into into physical physical therapy therapy ses- ses sions sions held held 33 days days 6. Therapeutic Interventions a a week week and and occupational occupational therapy therapy sessions sessions held held 2 2 days days a a week, week, continu- continu ing ing in in this this intensive Interventionsintensive manner mannerfrom for recovery until 18 18 months. untilNBPP months. Sessions Sessions lasted were incorporated lasted 45’ 45’ to into physical to 60’, 60’, but therapy the the child’s but ses- child’s tolerance tolerance was was taken taken into into account. account. It It is is important important to to sions held 3 days a week and occupational therapy sessions held 2 days a week, continuing note note that that many many of of the the intervention intervention strategies strategies in carried carried this intensive mannerout out inin the untilthe18sessions months.were sessions were Sessionstaught taught lasted to the to45’thetoparents parents in 60’, but thein aachild’s collaborative tolerance way, collaborative way, so so that was they they could that taken reproduce into account. could reproduce It is these these exercises important to noteat exercises home atthat homemany at at different of times times of the intervention different the the day, day, thus of strategies thus in- in carried creasing creasing outthe theinrehabilitation the sessions were rehabilitation taught to potential potential of the of theparents the child child with in a collaborative with NBPP. NBPP. way, so that they couldThis reproduce This child these child underwent exercises underwent an at home an intensive at intensive early different times early rehabilitation of the rehabilitation processday, thus process based increasing based on the on neurodevel- neurodevel rehabilitation potential of the child with NBPP. opmental opmental techniques techniques (neurological, (neurological, sensory, sensory, and and motor motor development), development), musculoskeletal musculoskeleta This child underwent an intensive early rehabilitation process based on neurodevel- techniques, techniques, and and individualised individualised muscle-strengthening muscle-strengthening strategies. strategies. Different Different intervention intervention opmental techniques (neurological, sensory, and motor development), musculoskeletal strategies strategies were techniques, were incorporated incorporated considering and individualised considering the muscle-strengthening the child’s child’s development development strategies. Different and and the the emergence emergence of intervention o more more functions functions in in the the arm arm affected affected by by the the injury. injury. strategies were incorporated considering the child’s development and the emergence of morePhysical functionstherapy Physical therapy in the arm and and occupational occupational affected therapy by the injury.therapy started started at at 11 11 days days of of age. age. InIn aa first first phase phase parents parents were Physical taught weretherapy taught and the the importance occupationalof importance maintaining therapy of started proper maintaining at 11 days proper posture of age.of posture Inthe of limb a first the limb throughout phase, throughou parents the daywere the day to to keeptaught keep joint jointthe importance range range of of motionof maintaining motion and and prevent prevent proper posture postural postural of the limb patterns, patterns, through- anteroposterior anteroposterior cap- cap out sule the day retraction,to keep joint contractures,range of and motion and deformities; prevent postural efforts sule retraction, contractures, and deformities; efforts were made to keep the affected armwere patterns, made to anteroposterior keep the affected arm capsule in retraction, contractures, and deformities; efforts wereamade to keep the affected in external external rotation rotation with with the the help help of of aa torsion torsion bandage bandage or or a weight weight (Figures (Figures 11 and and 2).2). These These arm in external rotation with the help of a torsion bandage or a weight (Figures 1 and 2). strategies strategies were used when the child was at rest, with the aim of integrating the limb into were used when the child was at rest, with the aim of integrating the limb into These strategies were used when the child was at rest, with the aim of integrating the limb ainto a symmetrical symmetrical posture posture and and pattern pattern appropriate appropriate to to the the a symmetrical posture and pattern appropriate to the stage of the child’s develop- stage stage of of the the child’s child’s development development by by physiologically physiologically ment by physiologicallyaligning aligning the aligning shoulder, the shoulder, arm, arm,arm, the shoulder, forearm, forearm, forearm,and andandhand handhandjoints, joints, preventing preventing joints, expected preventingexpected retractions/contractures retractions/contractures expected retractions/contractures and and deformities deformities and deformities (e.g., shoulder (e.g., (e.g., shoulder dysplasia) shoulderdysplasia) dysplasia) and and promoting/facili- andpromoting/facili- promot- tating tating the the most ing/facilitating most normal normal developmental the most developmental sequence normal developmental sequence possible. sequencepossible. possible. Figure Figure 1.Twist Figure1.1. Twiststrap. Twist strap. strap. Figure 2.Weight Figure2.2. Figure Weight Weighttoto maintain to posture. maintain maintain posture. posture. Passive mobilisations of the affected limb were taught to the parents, who repro- duced them several times throughout the day. These were essential to avoid joint stiffness and maintain joint range; they had to be performed gently and with each compromised Children Children 2022, 2022, 9, 9, x x FOR FOR PEER PEER REVIEW REVIEW 7 7 of of 1 1 Passive Passive mobilisations mobilisations of of the the affected affected limb limb were were taught taught toto the the parents, parents,7 ofwho who repro Children 2022, 9, 1298 16 repro duced them several times throughout the day. These were essential duced them several times throughout the day. These were essential to avoid joint stiffnesto avoid joint stiffnes and and maintain maintain joint joint range; range; they they had had toto be be performed performed gently gently and and with with each each compromised compromised joint. These passive mobilisations included shoulder external rotation, shoulder joint. These passive mobilisations included shoulder external rotation, shoulder flexion, flexion joint. These passive mobilisations included shoulder external rotation, shoulder flexion elbow elbow flexion elbowflexion flexion and and and extension, extension, extension, forearm forearm forearm supination, supination, supination, and and and and wrist wrist wrist and finger finger extension. andextension. finger These Thes extension. Thes mobilisations mobilisations mobilisationswere were were performed performed performed on on on this thisthis child child in in sets child sets of 10 repetitions of 10ofrepetitions in sets of the movement, of theofmovement, 10 repetitions the movement,4 44 tt 55 times to 5 timesa times a aday. day.Passive day. Passivemobilisations Passive (Figures (Figures33 mobilisations (Figures mobilisations and 3and 4), 4),inin and4), addition inaddition addition toto preserving preserving to preserving thethe the func func tional tional capacity of the joints, are an important source of proprioceptive stimulation for functionalcapacity of capacity the of thejoints, joints,are are an an important important source source of of proprioceptive proprioceptive stimulation stimulation for for th th the integration integration andrecovery and recovery of of the the affected affected nerves. nerves. integration and recovery of the affected nerves. Figure Figure3.3. Figure Passive 3.Passive Passive mobilisation mobilisation mobilisation of of shoulder of shoulder flexion, flexion, shoulder with with scapula with scapula flexion, support. support. scapula support. Figure 4. Passive mobilisation, elbow flexion. Figure4.4.Passive Passive mobilisation, elbow flexion. Figure mobilisation, elbow flexion. Inpassive InIn passive passive mobilisations, mobilisations, mobilisations, one ofone of theof one theimportant most the most important most important movements movements is the is the external movements is the external rota rotation external rota of the tion shoulder with the scapula stabilised to prevent contracture in tion of the shoulder with the scapula stabilised to prevent contracture in the internal rota of the shoulder with the scapula stabilised to prevent the contractureinternal in rotation the internal rota of theof tion shoulder the and shoulder shoulder and deformity shoulder (glenohumeral deformity dysplasia,dysplasia, (glenohumeral as this is the asproblem this is the prob tion of the shoulder and shoulder deformity (glenohumeral dysplasia, as this is the prob that lem generates most disability in NBPP).in Performing this movement several times a several day in- lem that creasedthat generates generates shoulder most mostand flexibility disability disability prevented NBPP). NBPP). Performing in shoulder Performing deformity andthis this movement movement shortening several times and atrophy times day day increased shoulder flexibility and prevented shoulder deformity and and shortening and shortening of theincreased subscapularis shoulder muscle,flexibility and glenohumeral thus delaying prevented shoulder deformity.deformity Passive mobilisations and atrophy atrophy were veryof of the subscapularis the subscapularis important muscle, muscle, in the first three months thus delaying thusofdelaying glenohumeral glenohumeral life, as they took into account deformity. deformity. Passive Passive mo the child’s mo bilisations bilisations were development were and thevery very important important inability in in the the first to stimulate with three first three months months intentional of of life, as life,(as activities they asits they took took into development into accoun accoun the did child’s thenot development yet allow child’s it), but wereand development and the inability maintained to throughout the inability stimulate with the first and to stimulate intentional withsecond activities years ofactivities intentional life. (as (as it it development In addition did to not passive yet allow it), mobilisations, but were tactile, maintained and throughout proprioceptive development did not yet allow it), but were maintained throughout the first and second the sensitivity first was and also second stimulated years years of (Figure 5) in the affected arm through tactile stimulation with materials of of life. life. different In textures, sizes, shapes, temperatures, tactile, vibrations (soft brush, electric toothbrush,was als In addition addition to to passive passive mobilisations, mobilisations, tactile, and and proprioceptive proprioceptive sensitivity sensitivity was als feathers, stimulated bath bags, (Figure ice, 5) etc.), in theand also affectedby sucking arm on through the thumb tactile of the hand with stimulation of thematerials injured stimulated (Figure 5) in the affected arm through tactile limb. This strategy provides sensorimotor input and promotes oculomotor coordination stimulation with materials of of dif dif ferent ferent textures, textures, sizes, shapes, sizes,ofshapes, temperatures, temperatures, vibrations vibrations (soft brush, electric toothbrush and central integration the affected limb, increasing sensory(soft brush,ofelectric perception the injuredtoothbrush feathers, feathers, bath bath bags, bags, ice, ice, arm as an integral part of the body. etc.), etc.), and and also also by by sucking sucking on on the the thumb thumb of of the the hand hand of of the the injured injured limb. limb. This This strategy strategy provides provides sensorimotor sensorimotor input input and and promotes promotes oculomotor oculomotor coordination coordination Children2022, Children 2022,9,9,xxFOR FORPEER PEERREVIEW REVIEW 88 of of 17 17 Children 2022, 9, x FOR PEER REVIEW 8 of 1 and central and central integration integration of of the the affected affected limb, limb, increasing increasing sensory sensory perception perception of of the the injured injured Children 2022, 9, 1298 8 of 16 and as arm central an integration integral part ofthe of thebody. affected limb, increasing sensory perception of the injured arm as an integral part of the body. arm as an integral part of the body. Figure5. Figure 5.Sensory Sensorystimulation stimulationwith withaasoft softbrush. brush. Figure5.5.Sensory Figure Sensory stimulation stimulation withwith a softa brush. soft brush. Following the Following the child’s child’s neurosensory neurosensory motor motor development, development, from from thethe age age ofof 33 months months onwards, Following onwards, active themobilisation child’s active mobilisation Fo