Pediatric Evaluation of Disability Inventory: its application to children with obstetric brachial plexus palsy

Quality of upper extremity skills and disability inventory via manual ability classification in children with neonatal brachial plexus palsy

PURPOSE

The aim of study was to investigate the relationship between upper extremity skill quality and disability inventory according to manual ability classification system in children with neonatal brachial plexus palsy (NBPP).

MATERIALS AND METHODS

Children with NBPP were included between the ages of 4-7.5 years. Children were classified in Manual Ability Classification System (MACS). Upper extremity skill quality was evaluated with Quality of Upper Extremity Skills Test (QUEST), disability status was assessed with Pediatric Evaluation of Disability Inventory (PEDI).

RESULTS

Total of 63 children (girls:31/boys:32), and mean age was 6.32 ± 1.73 years. 37 (58.73%) of children were at MACS Level-2. According to MACS classification, significant differences were noted in PEDI scores (p = 0.001), dissociated movements (p = 0.016) and grasp (p = 0.002) domains of QUEST. However, no significant differences between QUEST total scores (p = 0.079). PEDI (ROC; AuC = 0.762) and QUEST total score (ROC; AuC = 0.714) were sensitive to difference between groups across MACS in children with NBPP.

CONCLUSION

The PEDI and QUEST are sensitive in distinguishing the disability of children with NBPP at different MACS levels. Assessment of children with NBPP is not limited to functionality, disability, and quality of movement, it is multidimensional. Outcomes measures studies of movement's quality in children with NBPP are needed.

"How Well" and "How Often" questions for birth brachial plexus injury: a validity and reliability of the pediatric upper extremity motor activity log-revised

PURPOSE

The pediatric upper extremity motor activity log-revised (PMAL-R) is a structured interview that measures use of the affected arm in daily life in children with unilateral pathologies like hemiparetic cerebral palsy (CP) or birth brachial plexus injury (BBPI). This study investigated validity and test-retest reliability of the PMAL-R in children with BBPI.

MATERIALS AND METHODS

The PMAL-R was administered to parents of 132 children with BBPI between 5 and 9 years for validity, also 98 parents were re-interviewed after 3 weeks to establish test-retest reliability. Its concurrent validity was examined by correlating scores on the PMAL-R How Well (HW) and How Often (HO) scales with Brachial Plexus Outcome Measure (BPOM) and Pediatric Outcomes Data Collection Instrument (PODCI) scores.

RESULTS

PMAL-R scores were strongly correlated with BPOM scores (HW, r = 0.943, p < 0.001; HO, r = 0.897, p < 0.001), also strongly correlated with PODCI (HW, r = 0.799, p < 0.001; HO, r = 0.797, p < 0.001). PMAL-R test-retest reliability (intraclass correlation; HO = 0.997, HW = 0.998) and internal consistency (Cronbach's a; HO = 0.99, HW = 0.99) were high.

CONCLUSIONS

The PMAL-R has good reliability and validity for measuring everyday use of the affected arm with "how often" and "how well" questions in children with BBPI. Implications for rehabilitationThe pediatric upper extremity motor activity log-revised (PMAL-R) is the first tool to assess both "how often" and "how well" the affected arm is used in unimanual activities in children with BBPI.PMAL-R is a real-world measure providing valuable information about "how often" and "how well" the affected arm is used to guide treatment.PMAL-R is valid in both concurrent and discriminative validity in children with BBPI.PMAL-R is reliable in children with BBPI.

Quality of patient- and proxy-reported outcomes for children with impairment of the upper extremity: a systematic review using the COSMIN methodology

Background

As patient-reported outcome measures (PROMs) have become of significant importance in patient evaluation, adequately selecting the appropriate instrument is an integral part of pediatric orthopedic research and clinical practice. This systematic review provides a comprehensive overview of PROMs targeted at children with impairment of the upper limb, and critically appraises and summarizes the quality of their measurement properties by applying the COnsensus-based Standards for selection of health Measurement INstruments (COSMIN) methodology.

Methods

A systematic search of the MEDLINE and EMBASE databases was performed to identify relevant publications reporting on the development and/or validation of PROMs used for evaluating children with impairment of the upper extremity. Data extraction and quality assessment (including a risk of bias evaluation) of the included studies was undertaken by two reviewers independently and in accordance with COSMIN guidelines.

Results

Out of 6423 screened publications, 32 original articles were eligible for inclusion in this review, reporting evidence on the measurement properties of 22 self- and/or proxy-reported questionnaires (including seven cultural adaptations) for various pediatric orthopedic conditions, including cerebral palsy (CP) and obstetric brachial plexus palsy (OBPP). The measurement property most frequently evaluated was construct validity. No studies evaluating content validity and only four PROM development studies were included. The methodological quality of these development studies was either ‘doubtful’ or ‘inadequate’. The quantity and quality of the evidence on the other measurement properties of the included questionnaires varied substantially with insufficient sample sizes and/or poor methodological quality resulting in significant downgrading of evidence quality.

Conclusion

This review provides a comprehensive overview of currently available PROMs for evaluation of the pediatric upper limb. Based on our findings, none of the PROMs demonstrated sufficient evidence on their measurement properties to justify recommending the use of these instruments. These findings provide room for validation studies on existing pediatric orthopedic upper limb PROMs (especially on content validity), and/or the development of new instruments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00469-4.

Differences in the perspectives of functioning and health in the ICF model between patients with brachial plexus birth injury and their parents versus healthcare professionals

PURPOSE

To explore and compare the perspectives of patients and their parents (PPs) with a brachial plexus birth injury (BPBI) with those of health care professionals (HCPs).

MATERIALS AND METHODS

We conducted a study using a questionnaire among PPs and HCPs. Importance of different outcome categories was scored on a Likert scale. Items were linked to corresponding categories of the International Classification of Functioning, Disability and Health. Means were compared using analysis of variance (ANOVA).

RESULTS

Data were collected from 184 patients and 65 HCPs. We found a difference in 7/14 outcome categories between joint PP groups and HCPs. Parents scored outcome evaluation categories as more important than patients, categories filled out together by patient and parent scored in between (p < 0.05). The majority of PPs and HCPs rated outcome assessment as important in more domains than "Body functions" and "Body structures". The biggest difference was found in the importance of evaluation of pain.

CONCLUSIONS

Outcome assessment in the domains "Activities and participation" and "Environmental factors" was rated as important by both PPs and HCPs. Evaluation of pain was more often scored as important by PPs. Different domains seem to be underestimated by HCPs and need more attention during consultation. Implications for rehabilitationThe importance of outcome evaluation concerning "Pain", "Interaction with peers", and "Interaction with medical and paramedical specialists" should be taken into account in the rehabilitation for this specific group of patients and their parents (PPs).Comparison of perspectives on functioning between brachial plexus birth injury (BPBI) PPs and health care professionals.Outcome assessment in domains "Activities and participation" and "Environmental factors" is important.Health care professionals undervalue the importance of pain evaluation in BPBI as compared with PPs.

Modified constraint induced movement therapy in children with obstetric brachial plexus palsy: a systematic review

INTRODUCTION

Obstetric brachial plexus palsy (OBPP) is a flaccid paralysis occurring in the upper limb during birth. The OBPP includes mild lesions with complete spontaneous recovery and severe injuries with no regain of arm function. Among the most promising rehabilitation treatments aimed at improving upper extremity motor activities in individuals with neurological dysfunctions, there is the modified constraint-induced movement therapy (mCIMT). The aim of this systematic review is to assess and synthesize the critical aspects of the use of mCIMT in children with OBPP.

EVIDENCE ACQUISITION

This systematic review has been carried out according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis). A comprehensive search of the literature was conducted using PubMed, MEDLINE and Evidence Based Medicine Reviews, databases. We enclosed experimental and original articles, case reports and book chapters. Four articles were finally included.

EVIDENCE SYNTHESIS

One case report tested the feasibility of mCIMT to encourage use of the affected arm in a child with Erb-Duchenne palsy and documented the clinical changes observed. A case series had the purpose to determine if mCIMT in combination with botulinum toxin (BTX-A) improved arm function in 2 children with OBPP. A cohort study compared the use of mCIMT in 19 OBPP and 18 unilateral Cerebral Palsy. A prospective single-blind RCT described mCIMT versus conventional therapy in a group of 39 children with OBPP.

CONCLUSIONS

This systematic review on the use of mCIMT in children with OBPP shows that there is unanimous agreement that a program should last 2 weeks at least. However, there is no scientific evidence supporting a single common mCIMT protocol in the management of OBPP because of a considerable heterogeneity. Further high methodological studies regarding the application of mCIMT for OBPP and based on larger patients' sample should have the potential to optimize the appropriateness of care provided to infants with OBPP and, therefore, their quality of life.

Modified constraint-induced movement therapy during hospitalization in children with perinatal brachial plexus palsy: A randomized controlled trial

STUDY DESIGN

Prospective single-blind, randomized controlled study.

INTRODUCTION

Children with perinatal brachial plexus palsy (PBPP) have motion limitations in the affected upper extremity. Modified constraint-induced movement therapy (mCIMT) is one of the treatment options used for the improvement of the function of the affected limb.

PURPOSE OF THE STUDY

The purpose of this study was to compare the effect of mCIMT and conventional therapy in improving active range of motion (ROM) and functional use of the affected upper extremity in children with PBPP with injuries to upper and middle trunks in the hospital environment.

MATERIALS

26 patients received conventional rehabilitation program (control group) and 13 patients participated in a mCIMT program (study group). Children had a mean age 56.3 months (range 4-10 years). The mCIMT included 1 hour therapy sessions emphasizing the affected arm use for 14 consecutive days during hospitalization. Their normal arm was also constrained for 6 hour per day. All the patients were assessed at the baseline, one day, one month, and three months after completion of therapy using active ROM, active movement scale, hand dynamometer, box and blocks test.

RESULTS

The mCIMT group improved more than the control group in shoulder internal rotation, forearm supination, elbow flexion active ROMs, hand grip strength, and in upper extremity function.

CONCLUSION

mCIMT has a potential to promote functional gains for children with PBPP; this approach should be widely applied within routine clinical practice.

Conventional and Virtual Reality Mirror Therapies in Upper Obstetric Brachial Palsy: A Randomized Pilot Study

The abilities of children diagnosed with Obstetric Brachial Palsy (OBP) are limited by brachial plexus injuries. Thus, their participation in the community is hindered, which involves a lower quality of life due to worse performance in activities of daily living as a consequence of the functional limitations of the affected upper limb. Conventional Mirror Therapy (Conventional MT) and Virtual Therapy improve the affected upper limb functionality. Therefore, the aim of this study was to compare the effects of Conventional MT and Virtual Reality MT on the spontaneous use of the affected upper limb and quality of life of children with upper Obstetric Brachial Palsy between 6 and 12 years of age. A randomized pilot study was performed. Twelve children were randomly assigned to perform Conventional Mirror Therapy or Virtual Reality Mirror Therapy for four weeks. Ten children completed the treatment. Two assessments (pre/post-intervention) were carried out to assess the spontaneous use of the affected upper limb and the quality of life using the Children’s Hand-use Experience Questionnaire (CHEQ) and the Pediatric Quality of Life Inventory Generic Core Scales (PedsQL TM 4.0), respectively. There was a statistically significant increment in spontaneous use, observed in independent tasks (p = 0.02) and in the use of the affected hand with grasp (p = 0.04), measured with the CHEQ, for the Virtual Reality MT group. There were no statistically significant changes (p > 0.05) for the Conventional MT group in the spontaneous use of the affected upper limb. Regarding the quality of life, statistically significant changes were obtained in the Physical and Health activity categories of the parents’ questionnaire (p = 0.03) and in the total score of the children’s questionnaire (p = 0.04) in the Virtual Reality MT group, measured using the PedsQL TM 4.0. Statistically significant changes were not obtained for the quality of life in the Conventional MT group. This study suggests that, compared to Conventional MT, Virtual Reality MT would be a home-based therapeutic complement to increase independent bimanual tasks using grasp in the affected upper limb and improve the quality of life of children diagnosed with upper OBP in the age range of 6–12 years.

An Update on the Management of Neonatal Brachial Plexus Palsy-Replacing Old Paradigms: A Review

IMPORTANCE

Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, "all neonatal brachial plexus palsy recovers," "wait a year to see if recovery occurs," and "don't move the arm." Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms.

OBSERVATIONS

Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function.

CONCLUSIONS AND RELEVANCE

Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.

Clinical assessment of the infant and child following perinatal brachial plexus injury

STUDY DESIGN

Literature review.

INTRODUCTION

After perinatal brachial plexus injury (PBPI), clinicians play an important role in injury classification as well as the assessment of recovery and secondary conditions. Early assessment guides the initial plan of care and influences follow-up and long-term outcome.

PURPOSE

To review methods used to assess, classify and monitor the extent and influence of PBPI with an emphasis on guidelines for clinicians.

METHODS

We use The International Classification of Functioning, Disability, and Health (ICF) model to provide a guide to assessment after PBPI for rehabilitation clinicians.

DISCUSSION

With information gained from targeted assessments, clinicians can design interventions to increase the opportunities infants and children have for optimal recovery and to attain skills that allow participation in areas of interest.

Neonatal brachial plexus palsy--management and prognostic factors

Successful treatment of patients with neonatal brachial plexus palsy (NBPP) begins with a thorough understanding of the anatomy of the brachial plexus and of the pathophysiology of nerve injury via which the brachial plexus nerves stretched in the perinatal period manifest as a weak or paralyzed upper extremity in the newborn. NBPP can be classified by systems that can guide the prognosis and the management as these systems are based on the extent and severity of nerve injury, anatomy of nerve injury, and clinical presentation. Serial physical examinations, supplemented by a thorough maternal and perinatal history, are critical to the formulation of the treatment plan that relies upon occupational/physical therapy and rehabilitation management but may include nerve reconstruction and secondary musculoskeletal surgeries. Adjunctive imaging and electrodiagnostic studies provide additional information to guide prognosis and treatment. As research improves not only the technical aspects of NBPP treatment but also the ability to assess the activity and participation as well as body structure and function of NBPP patients, the functional outcomes for affected infants have an overall optimistic prognosis, with the majority recovering adequate functional use of the affected arm. Of importance are (i) early referral to interdisciplinary specialty clinics that can provide up-to-date advances in clinical care and (ii) increasing research/awareness of the psychosocial and patient-reported quality-of-life issues that surround the chronic disablement of NBPP.

Understanding quality of life and patient expectations among adolescents with neonatal brachial plexus palsy: a qualitative and quantitative pilot study

PURPOSE

To explore the quality of life (QOL) and patient expectations among adolescents with neonatal brachial plexus palsy (NBPP)and their parents using qualitative and quantitative approaches.

METHODS

A total of 18 adolescents (10-17 y) with residual NBPP impairment and their parents under went separate 1-hour tape-recorded semistructured interviews. We also collected quantitative physical examination measures and patient-rated outcome scores, specifically the Pediatric Outcomes Data Collection Instrument and the Child Health Questionnaire, to quantify the severity of each adolescent’s functional deficit and increase our understanding of QOL and patient expectations.

RESULTS

Through qualitative analysis, we identified several patient- and system-dependent factors contributing to QOL, such as social impact and peer acceptance, emotional adjustment,aesthetic concerns and body image, functional limitations, physical and occupational therapy, finances, pain, and family dynamics. Despite residual impairment, most adolescents and their parents reported a good overall QOL according to quantitative outcome measures. Our study results showed that functional and aesthetic factors were responsible for most observed differences in QOL among NBPP adolescents. We also found that the Pediatric Outcomes Data Collection Instrument might be more sensitive than the Child Health Questionnaire in assessing patient expectations and QOL among this patient population.

CONCLUSIONS

Understanding patient expectations and QOL in NBPP adolescents is essential for medical decision making and advancing care. Physical examination measurements alone may not be sufficient for measuring outcome, and knowledge regarding environmental factors and family dynamics is important for clinicians to consider when counseling families of children with NBPP and improving overall outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Concepts of functioning and health important to children with an obstetric brachial plexus injury: a qualitative study using focus groups

AIMS

The aims of this study were to explore and understand the perspectives of children with an obstetric brachial plexus injury (OBPI) regarding functioning and health, and to create an overview of problems and difficulties that patients encounter in daily life.

METHOD

We conducted a focus group study with 48 children (25 male, 23 female), aged 8 to 18 years, with an OBPI. Eleven open-ended questions regarding problems or difficulties in daily life were asked in group sessions with 4 to 7 children within the same age range. These group sessions were tape-recorded and transcribed verbatim. All problems and difficulties mentioned in each focus group were linked to corresponding categories of the International Classification of Functioning, Disability and Health - Children & Youth Version (ICF-CY).

RESULTS

Eight focus groups were conducted. A total of 143 unique ICF-CY categories were identified. Of these categories, 61 (43%) were related to the ICF-CY component 'activities and participation', 31 (22%) were related to 'body functions', 29 (20%) were related to 'environmental factors', and 22 (15%) were related to 'body structures'.

INTERPRETATION

This study shows that children with OBPI experience difficulties in all areas of functioning, as well as in both environmental and personal factors.

Psychometric properties of outcome measures for children and adolescents with brachial plexus birth palsy: a systematic review

AIM

The aim of this review was to evaluate the psychometric properties of outcome measures used to quantify upper limb function in children and adolescents with brachial plexus birth palsy (BPBP).

METHOD

Eleven electronic databases were searched to identify studies on the effects of conservative management to improve upper limb function in young people with BPBP. Outcome measures used in these studies were extracted and used in a subsequent search to identify studies that evaluated the psychometric properties of these measures. The methodological quality of these studies was rated using a standardized critical appraisal tool.

RESULTS

Thirty-three outcome measures and 12 psychometric studies were identified. Nine outcome measures had some psychometric evidence, which was variable in quality. The outcome measures which seem to have the most robust psychometric properties include the Active Movement Scale, Assisting Hand Assessment, Pediatric Evaluation of Disability Index, and the Pediatric Outcomes Data Collection Instrument.

INTERPRETATION

Further research is required to determine the psychometric properties of outcome measures used for children and adolescents with BPBP. Caution is required when interpreting the results of commonly used outcome measures in this population owing to their relatively unknown psychometric properties.

A systematic review of evaluation methods for neonatal brachial plexus palsy: a review

OBJECT

Neonatal brachial plexus palsy (NBPP) affects 0.4-2.6 newborns per 1000 live births in the US. Many infants recover spontaneously, but for those without spontaneous recovery, nerve and/or secondary musculoskeletal reconstruction can restore function to the affected arm. This condition not only manifests in a paretic/paralyzed arm, but also affects the overall health and psychosocial condition of the children and their parents. Currently, measurement instruments for NBPP focus primarily on physical ability, with limited information regarding the effect of the disablement on activities of daily living and the child's psychosocial well-being. It is also difficult to assess and compare overall treatment efficacy among medical (conservative) or surgical management strategies without consistent use of evaluation instruments. The purpose of this study is to review the reported measurement evaluation methods for NBPP in an attempt to provide recommendations for future measurement usage and development.

METHODS

The authors systematically reviewed the literature published between January 1980 and February 2012 using multiple databases to search the keywords "brachial plexus" and "obstetric" or "pediatrics" or "neonatal" or "congenital." Original articles with primary patient outcomes were included in the data summary. Four types of evaluation methods (classification, diagnostics, physical assessment, and functional outcome) were distinguished among treatment management groups. Descriptive statistics and 1-way ANOVA were applied to compare the data summaries among specific groups.

RESULTS

Of 2836 articles initially identified, 307 were included in the analysis, with 198 articles (9646 patients) reporting results after surgical treatment, 70 articles (4434 patients) reporting results after medical treatment, and 39 articles (4247 patients) reporting results after combined surgical and medical treatment. Among medical practitioners who treat NBPP, there was equivalence in usage of classification, diagnostic, and physical assessment tools (that focused on the Body Function and Structures measure of the International Classification of Functioning, Disability, and Health [ICF]). However, there was discordance in the functional outcome measures that focus on ICF levels of Activity and Participation. Of the 126 reported evaluation methods, only a few (the Active Movement Scale, Toronto Scale Score, Mallet Scale, Assisting Hand Assessment, and Pediatric Outcomes Data Collection Instrument) are specifically validated for evaluating the NBPP population.

CONCLUSIONS

In this review, the authors demonstrate disparities in the use of NBPP evaluation instruments in the current literature. Additionally, valid and reliable evaluation instruments specifically for the NBPP population are significantly lacking, manifesting in difficulties with evaluating the overall impact and effectiveness of clinical treatments in a consistent and comparative manner, extending across the various subspecialties that are involved in the treatment of patients with NBPP. The authors suggest that all ICF domains should be considered, and future efforts should include consideration of spontaneous (not practitioner-elicited) use of the affected arm in activities of daily living with attention to the psychosocial impact of the disablement.

The brachial plexus outcome measure: development, internal consistency, and construct validity

PURPOSE

The purpose of this article was to report the development of a new assessment tool, the Brachial Plexus Outcome Measure (BPOM) and the evaluation of its internal consistency and construct validity.

METHODS

A retrospective case series of children aged 4-19 years with obstetrical brachial plexus palsy (OBPP) was conducted. Intraclass coefficients were calculated for the BPOM Activity Scale items. Correlation between the Active Movement Scale (AMS) and BPOM Activity Scale scores were conducted to determine the convergent validity.

RESULTS

The BPOM Activity Scale items (N=306) had good internal consistency (Cronbach's α=0.87). A strong correlation between the BPOM Activity Scale and AMS (n=284) was found (r=0.71, p=0.001, α=0.05).

CONCLUSIONS

The BPOM Activity Scale demonstrates good internal consistency and construct validity as a discriminative functional outcome measure in children with OBPP.

LEVEL OF EVIDENCE

IV.

Development and evidence of validity for the Children's Hand-use Experience Questionnaire (CHEQ)

AIM

To describe the development of the Children's Hand-use Experience Questionnaire (CHEQ), and investigate the evidence of its validity based on test content and internal structure of the three scales in it.

METHOD

The selection of items and questions was based on a literature review, expert opinion, and interviews with families. Data on the final questionnaire were collected from 86 children and adolescents (42 males, 44 females) aged 6 to 18 years (mean 12 y, SD 3 y), with unilateral cerebral palsy, upper limb reduction deficiency, or obstetric brachial plexus palsy.

RESULTS

After item reduction and evaluation, CHEQ was designed to include 29 bimanual activities, each rated on three scales of perceived efficacy of the grasp, time taken to perform the activity, and degree of feeling bothered. The appropriateness of the included activities was confirmed by their reported relevance and bimanual nature. The internal structure of the scales was confirmed by Rasch analysis.

INTERPRETATION

CHEQ can be used to assess children and adolescents with a unilateral hand dysfunction on their experiences of using the affected hand to perform bimanual tasks. In clinical work, CHEQ has the potential to become a useful tool for treatment planning and follow-up.

Item bank development for a revised pediatric evaluation of disability inventory (PEDI)

The Pediatric Evaluation of Disability Inventory (PEDI) is a useful clinical and research assessment, but it has limitations in content, age range, and efficiency. The purpose of this article is to describe the development of the item bank for a new computer adaptive testing version of the PEDI (PEDI-CAT). An expanded item set and response options were reviewed by clinician experts and examined at parent and clinician focus groups. Eleven parents participated in 32 cognitive interviews to examine content, format, and comprehension of items and responses. A set of 76 self-care, 78 mobility, and 64 social function items with pictures and a four-point "Difficulty" scale were developed. The PEDI's Caregiver Assistance scale was replaced by a "Responsibility Scale" with 53 items. Content validity was established incorporating input from clinicians and parents. The new item bank covers a broad range of functional activities for children of all ages and abilities.

Obstetric brachial plexus palsy: treatment strategy, long-term results, and prognosis

BACKGROUND

Obstetric brachial plexus palsy is rare, but the limb impairments are manifold and often long-lasting. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed with success. The role of conservative and operative treatment options should be regularly reviewed.

METHODS

Selective literature review (evidence levels 3 and 4) and analysis of personal clinical operative and scientific experience over the past 15 years.

RESULTS

Children with upper and total plexus palsy displaying nerve root avulsions and/or -ruptures are treated today by early primary nerve reconstruction in the first few months of life followed by secondary corrections, with good functional results. The late complications, with muscle weakness, impaired motion patterns, and joint dysplasia, are often underrated.

CONCLUSIONS

The potential for scientific analysis is limited, due to the rarity and interindividual variability of the lesions and the varying effects on function and growth. Expectations and compliance are different in every patient. Surgical techniques are not yet standardized. Knowledge of the consequences for joint growth and congruence is inadequate. Today, functional improvement can be achieved by surgery in most clinical manifestations of obstetric brachial plexus palsy, within the framework of an interdisciplinary treatment concept.

Lyme disease--current state of knowledge

BACKGROUND

Lyme disease is the most frequent tick-borne infectious disease in Europe. The discovery of the causative pathogen Borrelia burgdorferi in 1982 opened the way for the firm diagnosis of diseases in several clinical disciplines and for causal antibiotic therapy. At the same time, speculation regarding links between Borrelia infection and a variety of nonspecific symptoms and disorders resulted in overdiagnosis and overtreatment of suspected Lyme disease.

METHOD

The authors conducted a selective review of the literature, including various national and international guidelines.

RESULTS

The spirochete Borrelia burgdorferi sensu lato is present in approximately 5% to 35% of sheep ticks (Ixodes ricinus) in Germany, depending on the region. In contrast to North America, different genospecies are found in Europe. The most frequent clinical manifestation of Borrelia infection is erythema migrans, followed by neuroborreliosis, arthritis, acrodermatitis chronica atrophicans, and lymphocytosis benigna cutis. Diagnosis is made on the basis of the clinical symptoms, and in stages II and III by detection of Borrelia-specific antibodies. In adults erythema migrans is treated with doxycycline, in children with amoxicillin. The standard treatment of neuroborreliosis is third-generation cephalosporins.

CONCLUSIONS

After appropriate antibiotic therapy, the outcome is favorable. In approximately 95% of cases neuroborreliosis is cured without long-term sequelae. When chronic borreliosis is suspected, other potential causes of the clinical syndrome must be painstakingly excluded.