Interrater reliability of face-to-face, tele- and video-based assessments with the modified Mallet classification in brachial plexus birth injuries

The modified Mallet classification is widely used to measure motor function in brachial plexus birth injuries. The aim of the study was to investigate agreement and reliability of this classification under three different evaluation conditions: face-to-face; live tele-assessment; and delayed video-based assessment. A total of 100 children aged 4-15 years were included. Children were assessed by two raters except for live tele-assessment, which was performed by four raters. Agreement between the three different assessment conditions for the same rater were between strong and excellent for both raters 1 and 2. The interrater reliability for raters 1 and 2 under different assessment conditions was strong to excellent. Interrater reliability among the four raters was moderate to strong in tele-assessment. The modified Mallet classification may have appropriate reliability to be used in remote medical follow-up.Level of evidence: III.

Complications in Surgery for Brachial Plexus Birth Injury: Avoidance and Treatment

Brachial plexus birth injuries are rare, with treatment and follow-up often required from infancy until skeletal maturity. We review complications that may occur related to primary nerve surgery or secondary musculoskeletal procedures, and discuss how these may be avoided.

[Application of Vojta's method for early detection of developmental disturbances in very low birthweight infants with regard to Apgar score and asymmetric body positions]

INTRODUCTION

This work focuses on the usefulness of assessment based on seven body positions according to Vojta for early detection of developmental abnormalities of the central nervous system. As additional factors, Apgar score at 1st and 5th minute of life, as well as asymmetry of head or of whole body at the time of investigation (usually third month of life) were analyzed in correlation with subsequent diagnosis of cerebral palsy usually established after the first year of life.

MATERIAL AND METHODS

The study group consisted of 57 children with birthweight lower than 1500 grams. Seven children were diagnosed with cerebral palsy at the age of one year.

RESULTS

The following conclusions were drawn: Vojta's diagnostic method is very sensitive in detecting injury of the central nervous system early in life; high correlation was found between cerebral palsy and asymmetry of the body, but not of the head; low Apgar score at 5th but not at 1st minute is highly predictive for progression to cerebral palsy in infants with very low birthweight.

Part 1. Injuries to the brachial plexus: mechanisms of injury and identification of risk factors

Upper-arm weakness (paresis) or paralysis indicates peripheral-nerve damage to the brachial plexus, a network of lower cervical and upper thoracic spinal nerves supplying the arm, forearm, and hand. Physical findings reflect muscle paralysis from spinal nerve roots. The mechanism of injury includes maternal, obstetric, and infant factors that apply traction on or compression to the anatomically vulnerable brachial plexus. Nerve regeneration can occur if nerve tissue components are preserved. Recovery is affected by multiple factors, including the type and site of injury, intervention timing, and developmental factors. The majority of injuries recover in days or months; however, residual deficits can persist. Part 1 of 2 of this article provides an overview of the neurophysiology of peripheral-nerve damage and nerve regeneration. The multifactorial etiology of brachial plexus injuries will be reviewed. Photographs and on-line video clips will enhance the description of the brachial plexus injury classifications and illustrate mechanisms of shoulder dystocia and obstetric relief maneuvers. A systematic approach to the physical examination will be explored in Part 2. Serial evaluation of motor function recovery is essential and is accomplished by appropriate referrals and follow-up. Part 2 will also describe treatment options and discuss anticipatory parent guidance.

The problem of obstetrical complications and schizophrenia

The use of the term "obstetrical complications" (OCs) and its variations to encompass diverse physiological mechanisms (e.g., genetic, ischemic, hemorrhagic, infectious) of disruption to fetal/neonatal brain development has engendered inconsistency, confusion, and controversy. The principal reason is that the term OCs belies the absence of a fully adequate conceptual framework for characterizing neurodevelopmental risk. We propose that neurodevelopmental risk factors for schizophrenia can be assessed more clearly if broad OC scales are replaced by measures representing more homogeneous pathways of disturbed brain development. Using a new OC classification, we found that disordered growth related to hypoxic-ischemic compromise to early brain development may confer an elevated risk of schizophrenia and other adult-onset psychoses, particularly in the presence of familial risk. Abnormal fetal and neonatal brain growth and development in schizophrenia and OCs may also, at least in part, result from genetic factors and could help explain the relation between seemingly inconsistent OCs identified in prior research.

An Apgar score of three or less at one minute is not diagnostic of birth asphyxia but is a useful screening test for neonatal encephalopathy

OBJECTIVE

To evaluate the relationship between an Apgar score of three or less at one minute of life and the subsequent risk of developing neonatal encephalopathy (NE).

DESIGN

Prospective.

SETTING

The principal maternity hospital of Kathmandu, Nepal, a low income country, where over 50% of the local population deliver.

METHODS

All liveborn infants over a 12 month period with a birthweight of 500 g or more were assessed by the Apgar scoring system at one minute of age. All term infants with neurological abnormalities presenting in the first day of life were systematically examined and described according to a conventionally defined encephalopathy grading system. Major congenital malformations and neonatal infections were excluded.

RESULTS

Over 12 months there were 14,771 total births of a weight of 500 g or more of which 14,371 were live births and 400 were stillbirths. Of 734 infants with 1 min Apgar of three or less, 91 developed NE. The positive and negative predictive values of 1 min Apgar of three or less for NE were 11.4% and 99.9%, respectively. The probability of developing NE rose from 0.6% (amongst all infants born at this hospital) to 11.2% (amongst infants born with a one minute Apgar of three or less).

CONCLUSIONS

An Apgar score of 3 or less at one minute is a useful screening test for clinically significant birth asphyxia (NE). It overestimates by eight fold the scale of the birth asphyxia problem, but identifies a high risk group requiring further observation of their neurological condition.

A new evaluation system to predict the sequelae of late obstetric brachial plexus palsy

Obstetric brachial plexus palsy has two distinct categories: (1) early obstetric brachial plexus palsy (or obstetric brachial plexus palsy in an infant) and (2) late obstetric brachial plexus palsy with deformity (or obstetric brachial plexus palsy in a child). Both early and late obstetric brachial plexus palsy lack a uniform evaluation system, and this makes correlation between them difficult. Clinical evaluation of obstetric brachial plexus palsy in infants is difficult, but in children it is easier. Here, we utilized a new evaluation system, called "Score of 10," to evaluate 121 late obstetric brachial plexus palsy patients based on patient's functional ability and surgeon's feasibility for reconstruction. "Score of 10" is a method combining the Erb and Klumpke scores. The Erb score gives points for upper plexus functions including shoulder abduction, shoulder external rotation, elbow flexion, elbow extension, forearm supination, forearm pronation, and trumpet sign. The Klumpke score gives points for lower plexus functions including wrist extension, wrist flexion, metacarpophalangeal joint extension, interphalangeal joint extension, finger flexion, thumb adduction, and thumb abduction. The aims of this evaluation system are to determine the relationships between early and late obstetric brachial plexus palsy, to predict the progressive changes that take place with aging, and to propose the possible operation procedures to reconstruct. However, this evaluation system may differ by time and may not be suitable for comparisons between pre- and postreconstruction.

[Standardization of evaluation and classification of disability manifestations in traumatic brachial plexus birth injury-induced paralysis]

The classification of miscellaneous clinical features in obstetric palsies is difficult due to variations during growth, regeneration, plexus repair and secondary surgery. Any useful comparison of different forms of therapy requires universally recognised norms of evaluation. Several proposals have already found clinical application. Their employment will help to unify the results of our evaluation.