Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline
Christopher J Coroneos, Sophocles H Voineskos, Marie K Christakis, Achilleas Thoma, James R Bain, Melissa C Brouwers, Canadian OBPI Working Group, Michael Bezuhly, Sean G Bristol, Kevin Cheung, Howard M Clarke, Kristen M Davidge, A Robertson Harrop, Jennifer C Lin, Jaret L Olson, Douglas C Ross, Constantin Stanciu, David Tang, Susan Thompson, Cynthia Verchere, Yvonne Ying, Christopher J Coroneos, Sophocles H Voineskos, Marie K Christakis, Achilleas Thoma, James R Bain, Melissa C Brouwers, Canadian OBPI Working Group, Michael Bezuhly, Sean G Bristol, Kevin Cheung, Howard M Clarke, Kristen M Davidge, A Robertson Harrop, Jennifer C Lin, Jaret L Olson, Douglas C Ross, Constantin Stanciu, David Tang, Susan Thompson, Cynthia Verchere, Yvonne Ying
Abstract
Objective: The objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing gaps: (1) historic poor use of evidence, (2) timing of referral to multidisciplinary care, (3) Indications and timing of operative nerve repair and (4) distribution of expertise.
Setting: The guideline is intended for all healthcare providers treating infants and children, and all specialists treating upper extremity injuries.
Participants: The evidence interpretation and recommendation consensus team (Canadian OBPI Working Group) was composed of clinicians representing each of Canada's 10 multidisciplinary centres.
Outcome measures: An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori. Quality indicators for referral to a multidisciplinary centre were established by consensus. An original meta-analysis of primary nerve repair and review of Canadian epidemiology and burden were previously completed.
Results: 7 recommendations address clinical gaps and guide identification, referral, treatment and outcome assessment: (1) physically examine for OBPI in newborns with arm asymmetry or risk factors; (2) refer newborns with OBPI to a multidisciplinary centre by 1 month; (3) provide pregnancy/birth history and physical examination findings at birth; (4) multidisciplinary centres should include a therapist and peripheral nerve surgeon experienced with OBPI; (5) physical therapy should be advised by a multidisciplinary team; (6) microsurgical nerve repair is indicated in root avulsion and other OBPI meeting centre operative criteria; (7) the common data set includes the Narakas classification, limb length, Active Movement Scale (AMS) and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery.
Conclusions: The process established a new network of opinion leaders and researchers for further guideline development and multicentre research. A structured referral form is available for primary care, including referral recommendations.
Keywords: OBSTETRICS.
Conflict of interest statement
Conflicts of Interest: None declared.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
References
- Tan KL. Brachial palsy. J Obstet Gynaecol Br Commonw 1973;80:60–2. 10.1111/j.1471-0528.1973.tb02132.x
- Coroneos CJ, Voineskos SH, Coroneos MK et al. . Primary nerve repair for obstetrical brachial plexus injury: a meta-analysis. Plast Reconstr Surg 2015;136:765–79. 10.1097/PRS.0000000000001629
- Newschaffer CJ, Croen LA, Daniels J et al. . The epidemiology of autism spectrum disorders. Annu Rev Public Health 2007;28:235–58. 10.1146/annurev.publhealth.28.021406.144007
- Patel H, Feldman M. Universal newborn hearing screening. Paediatr Child Health 2011;16:301–10.
- Newhook LA, Penney S, Fiander J et al. . Recent incidence of type 1 diabetes mellitus in children 0–14 years in Newfoundland and Labrador, Canada climbs to over 45/100,000: a retrospective time trend study. BMC Res Notes 2012;5:628 10.1186/1756-0500-5-628
- Farrell P, Joffe S, Foley L et al. . Diagnosis of cystic fibrosis in the Republic of Ireland: epidemiology and costs. Ir Med J 2007;100:557–60.
- Foad SL, Mehlman CT, Ying J. The epidemiology of neonatal brachial plexus palsy in the United States. J Bone Joint Surg Am 2008;90:1258–64. 10.2106/JBJS.G.00853
- Gjorup L. Obstetrical lesion of the brachial plexus. Acta Neurol Scand 1966;42(Suppl 18):1–80.
- Malessy MJA, Pondaag W, van Dijk JG. Electromyography, nerve action potential, and compound motor action potentials in obstetric brachial plexus lesions: validation in the absence of a “gold standard”. Neurosurgery 2009;65(4 Suppl):A153–9. 10.1227/01.NEU.0000338429.66249.7D
- Pondaag W, Malessy MJA, van Dijk JG et al. . Natural history of obstetric brachial plexus palsy: a systematic review. Dev Med Child Neurol 2004;46:138–44. 10.1111/j.1469-8749.2004.tb00463.x
- Bain JR, DeMatteo C, Gjertsen D et al. . Limb length differences after obstetrical brachial plexus injury: a growing concern. Plast Reconstr Surg 2012;130:558e–71e. 10.1097/PRS.0b013e318262f26b
- Waters PM. Update on management of pediatric brachial plexus palsy. J Pediatr Orthop B 2005;14:233–44. 10.1097/01202412-200507000-00001
- Alyanak B, Kılınçaslan A, Kutlu L et al. . Psychological adjustment, maternal distress, and family functioning in children with obstetrical brachial plexus palsy. J Hand Surg Am 2013;38:137–42. 10.1016/j.jhsa.2012.09.036
- Borschel GH, Clarke HM. Obstetrical brachial plexus palsy. Plast Reconstr Surg 2009;124(1 Suppl):144e–55e. 10.1097/PRS.0b013e3181a80798
- Smania N, Berto G, La Marchina E et al. . Rehabilitation of brachial plexus injuries in adults and children. Eur J Phys Rehabil Med 2012;48:483–506.
- Clarke HM, Al-Qattan MM, Curtis CG et al. . Obstetrical brachial plexus palsy: results following neurolysis of conducting neuromas-in-continuity. Plast Reconstr Surg 1996;97:974–82; discussion 983–4 10.1097/00006534-199604001-00014
- Laurent JP. Neurosurgical intervention for birth-related brachial plexus injuries. Neurosurg Q 1997;7:69–75.
- Mehta SH, Gonik B. Neonatal brachial plexus injury: obstetrical factors and neonatal management. J Pediatr Rehabil Med 2011;4:113–18.
- Zafeiriou DI, Psychogiou K. Obstetrical brachial plexus palsy. Pediatr Neurol 2008;38:235–42. 10.1016/j.pediatrneurol.2007.09.013
- Xu J, Cheng X, Dong Z et al. . Remote therapeutic effect of early nerve transposition in treatment of obstetrical brachial plexus palsy. Chin J Traumatol 2001;4:40–3.
- Waters PM. Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone Joint Surg Am 1999;81:649–59. 10.2106/00004623-199905000-00006
- Laurent JP, Lee R, Shenaq S et al. . Neurosurgical correction of upper brachial plexus birth injuries. J Neurosurg 1993;79:197–203. 10.3171/jns.1993.79.2.0197
- Gilbert A, Tassin JL. Obstetrical palsy: a clinical, pathologic, and surgical review. In: Terzis JK, ed. Microreconstruction of nerve injuries. Philadelphia: WB Saunders, 1987:529.
- Bain JR, Dematteo C, Gjertsen D et al. . Navigating the gray zone: a guideline for surgical decision making in obstetrical brachial plexus injuries. J Neurosurg Pediatr 2009;3:173–80. 10.3171/2008.12.PEDS0885
- Xu J, Cheng X, Gu Y. Different methods and results in the treatment of obstetrical brachial plexus palsy. J Reconstr Microsurg 2000;16:417–20; discussion 420–2 10.1055/s-2006-947147
- Terzis JK, Kostas I. Outcomes with suprascapular nerve reconstruction in obstetrical brachial plexus patients. Plast Reconstr Surg 2008;121:1267–78. 10.1097/
- Pondaag W, Gilbert A. Results of end-to-side nerve coaptation in severe obstetric brachial plexus lesions. Neurosurgery 2008;62:656–63; discussion 656–63 10.1227/01.neu.0000317314.54450.79
- Pondaag W, Malessy MJA. Recovery of hand function following nerve grafting and transfer in obstetric brachial plexus lesions. J Neurosurg 2006;105(1 Suppl):33–40.
- Pondaag W, de Boer R, van Wijlen-Hempel MS et al. . External rotation as a result of suprascapular nerve neurotization in obstetric brachial plexus lesions. Neurosurgery 2005;57:530–7; discussion 530–7 10.1227/01.NEU.0000170557.13788.D2
- Kawabata H, Kawai H, Masatomi T et al. . Accessory nerve neurotization in infants with brachial plexus birth palsy. Microsurgery 1994;15:768–72. 10.1002/micr.1920151105
- Lin H, Hou C, Chen D. Contralateral C7 transfer for the treatment of upper obstetrical brachial plexus palsy. Pediatr Surg Int 2011;27:997–1001. 10.1007/s00383-011-2894-4
- Lin JC, Schwentker-Colizza A, Curtis CG et al. . Final results of grafting versus neurolysis in obstetrical brachial plexus palsy. Plast Reconstr Surg 2009;123:939–48. 10.1097/PRS.0b013e318199f4eb
- Luo PB, Chen L, Zhou CH et al. . Results of intercostal nerve transfer to the musculocutaneous nerve in brachial plexus birth palsy. J Pediatr Orthop 2011;31:884–8. 10.1097/BPO.0b013e318230a783
- Chang KWC, Justice D, Chung KC et al. . A systematic review of evaluation methods for neonatal brachial plexus palsy. J Neurosurg Pediatr 2013. [Epub ahead of print]. .
- Sparagana SP, Ezaki M. Microneurosurgery for neonatal brachial plexus palsy: the need for more information. Arch Neurol 2006;63:1033–4. 10.1001/archneur.63.7.1033
- Squitieri L, Larson BP, Chang KWC et al. . Medical decision-making among adolescents with neonatal brachial plexus palsy and their families: a qualitative study. Plast Reconstr Surg 2013;131:880e–7e. 10.1097/PRS.0b013e31828bd52b
- Hoeksma AF, ter Steeg AM, Nelissen RGHH et al. . Neurological recovery in obstetric brachial plexus injuries: an historical cohort study. Dev Med Child Neurol 2004;46:76–83. 10.1111/j.1469-8749.2004.tb00455.x
- Smith NC, Rowan P, Benson LJ et al. . Neonatal brachial plexus palsy. Outcome of absent biceps function at three months of age. J Bone Joint Surg Am 2004;86-A:2163–70. 10.2106/00004623-200410000-00006
- Waters PM, Bae DS. Brachial plexus birth palsy: rationale for a multicenter prospective study. Semin Plast Surg 2004;18: 377–84. 10.1055/s-2004-837263
- Bodensteiner JB, Rich KM, Landau WM. Early infantile surgery for birth-related brachial plexus injuries: justification requires a prospective controlled study. J Child Neurol 1994;9:109–10. 10.1177/088307389400900201
- Malessy MJA, Pondaag W, Yang LJS et al. . Severe obstetric brachial plexus palsies can be identified at one month of age. PLoS ONE 2011;6:e26193 10.1371/journal.pone.0026193
- Bellew M, Kay SP. Early parental experiences of obstetric brachial plexus palsy. J Hand Surg Br 2003;28:339–46. 10.1016/S0266-7681(03)00081-0
- Clarke HM, Curtis CG. An approach to obstetrical brachial plexus injuries. Hand Clin 1995;11:563–80; discussion 580–1.
- Al-Qattan MM. The outcome of Erb's palsy when the decision to operate is made at 4 months of age. Plast Reconstr Surg 2000;106:1461–5. 10.1097/00006534-200012000-00003
- Gilbert A. Long-term evaluation of brachial plexus surgery in obstetrical palsy. Hand Clin 1995;11:583–94; discussion 594–5.
- Cancer Care Ontario. Program in evidence-based care handbook. 2012:1–14.
- Burgers JS, Smolders M, van der Weijden T et al. . Clinical practice guidelines as a tool for improving patient care. In: Grol R, Wensing M, Eccles M, Davis D, eds. Improving patient care: the implementation of change in health care. 2nd edn West Sussex: Wiley-Blackwell, 2013, chapter 6.
- Robinson KA, Saldanha IJ, McKoy NA. Identification of research gaps from evidence-based guidelines: a pilot study in cystic fibrosis. Int J Technol Assess Health Care 2011;27:247–52. 10.1017/S0266462311000225
- Wong RKS, Brierley J, Brouwers M. What is the best way to produce consensus and buy in to guidelines for rectal cancer? Curr Colorectal Cancer Rep 2012;8:83–9. 10.1007/s11888-012-0121-x
- Krahn M, Naglie G. The next step in guideline development: incorporating patient preferences. JAMA 2008;300:436–8. 10.1001/jama.2008.731
- Brouwers MC, Stacey D, O'Connor AM. Knowledge translation tools. In: Straus SE, Tetroe J, Graham ID, eds. Knowledge translation in health care: moving from evidence to practice. 1st edn West Sussex: Wiley-Blackwell, 2009, chapter 2.3.
- Grimshaw J, Eccles M, Thomas R et al. . Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966–1998. J Gen Intern Med 2006;21(Suppl 2):S14–20.
- Browman GP, Levine MN, Mohide EA et al. . The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 1995;13:502–12.
- Valente TW, Pumpuang P. Identifying opinion leaders to promote behavior change. Health Educ Behav 2007;34:881–96. 10.1177/1090198106297855
- Institute of Medicine of the National Academies. Knowing what works in health care: a roadmap for the nation. Eden J, Wheatley B, McNeil B, Sox H, eds. Washington DC: National Academies Press, 2008.
- Rosenfeld RM, Shiffman RN, Robertson P. Clinical Practice Guideline Development Manual, Third Edition: a quality-driven approach for translating evidence into action. Otolaryngol Head Neck Surg 2013;148(1 Suppl):S1–55. 10.1177/0194599812467004
- Bellew M, Kay SP, Webb F et al. . Developmental and behavioural outcome in obstetric brachial plexus palsy. J Hand Surg Br 2000;25:49–51. 10.1054/jhsb.1999.0331
- World Health Organization. International Classification of Functioning, Disability, and Health (ICF). Geneva, Switzerland: Organization WH, 2001.
- National Institute for Health and Clinical Excellence. The guidelines manual. London: National Institute for Health and Clinical Excellence, 2012.
- Phua PD, Al-Samkari HT, Borschel GH. Is the term “obstetrical brachial plexus palsy” obsolete? An international survey to assess consensus among peripheral nerve surgeons. J Plast Reconstr Aesthet Surg 2012;65:1227–32. 10.1016/j.bjps.2012.03.037
- Coroneos CJ, Voineskos SH, Coroneos MK et al. . Canadian OBPI Working Group. Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system. J Neurosurg Pediatr 2016;17:222–9.
- Shea BJ, Grimshaw JM, Wells GA et al. . Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7:10 10.1186/1471-2288-7-10
- Murphy MK, Black NA, Lamping DL et al. . Consensus development methods, and their use in clinical guideline development. Health Technol Assess 1998;2:i–iv, 1–88.
- Linstone HA, Turnoff M, eds. The Delphi Method: techniques and applications. Don Mills: Addison-Wesley Publishing, 2002.
- Loblaw DA, Prestrud AA, Somerfield MR et al. . American Society of Clinical Oncology Clinical Practice Guidelines: formal systematic review-based consensus methodology. J Clin Oncol 2012;30:3136–40. 10.1200/JCO.2012.42.0489
- Falkson CB, Bezjak A, Darling G et al. . The management of thymoma: a systematic review and practice guideline. J Thorac Oncol 2009;4:911–19. 10.1097/JTO.0b013e3181a4b8e0
- Fitch K, Bernstein SJ, Aguilar MD et al. . The RAND/UCLA appropriateness method user's manual. Santa Monica, CA: RAND, 2001.
- Shekelle PG, Woolf SH, Eccles M et al. . Clinical guidelines: developing guidelines. BMJ 1999;318:593–6. 10.1136/bmj.318.7183.593
- Fertig A, Roland M, King H et al. . Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates? BMJ 1993;307:1467–70. 10.1136/bmj.307.6917.1467
- Bialocerkowski A, O'shea K, Pin TW. Psychometric properties of outcome measures for children and adolescents with brachial plexus birth palsy: a systematic review. Dev Med Child Neurol 2013;55:1075–88. 10.1111/dmcn.12194
- Ho ES, Curtis CG, Clarke HM. The brachial plexus outcome measure: development, internal consistency, and construct validity. J Hand Ther 2012;25:406–16. 10.1016/j.jht.2012.05.002
- Yorkhill Hospital, Glasgow NOBPIS. Guidelines on initial management and referral of Obstetric Brachial Plexus Palsy (cited 15 February 2014).
- Storment M. GUIDELINES FOR THERAPISTS: Treating Children with Brachial Plexus Injuries 2014. (cited 15 February 2014).
- Musson R. Management of Congenital Brachial Plexus Injury. North Trent Neonatal Netw. Guidel 2011. (cited 15 February 2014).
- Barr S. Guideline for the management of Brachial Plexus Injury (BPI) 2010. (cited 15 February 2014).
- Crowther J, Losa D, Moran M. Guideline on Suspected/Actual Brachial Plexus Injury or any other injury associated with the complications of a Shoulder Dystocia Delivery 2013. (cited 15 February 2014). Trust/policies/M/Maternity Neonatal Brachial PlexusInjury1893.pdf
- Specialty Specific Guidelines 2013. (cited 15 February 2014).
- PAEDIATRIC PLASTIC AND RECONSTRUCTIVE SURGERY REFERRAL RECOMMENDATIONS. No Title. CPAC Guidel. Paediatr. Plast. Reconstr. Surg 2012. (cited 15 February 2014). Plastic Surgery CPAC Referral Recommendations 2013.pdf
- Andersen J, Watt J, Olson J et al. . Perinatal brachial plexus palsy. Paediatr Child Health 2006;11:93–100.
- Hentz VR, Meyer RD. Brachial plexus microsurgery in children. Microsurgery 1991;12:175–85. 10.1002/micr.1920120307
- Sjöberg I, Erichs K, Bjerre I. Cause and effect of obstetric (neonatal) brachial plexus palsy. Acta Paediatr Scand 1988;77:357–64. 10.1111/j.1651-2227.1988.tb10660.x
- al-Qattan MM, Al-Kharfy TM. Obstetric brachial plexus injury in subsequent deliveries. Ann Plast Surg 1996;37:545–8. 10.1097/00000637-199611000-00015
- Narakas AO. The treatment of brachial plexus injuries. Int Orthop 1985;9:29–36. 10.1007/BF00267034
- ter Steeg AM, Hoeksma AF, Dijkstra PF et al. . Orthopaedic sequelae in neurologically recovered obstetrical brachial plexus injury. Case study and literature review. Disabil Rehabil 2003;25:1–8. 10.1080/09638280210142185
- Bialocerkowski A, Kurlowicz K, Vladusic S et al. . Effectiveness of primary conservative management for infants with obstetric brachial plexus palsy. Int J Evid Based Healthc 2005;3:27–44.
- Curtis C, Stephens D, Clarke HM et al. . The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy. J Hand Surg Am 2002;27:470–8. 10.1053/jhsu.2002.32965
- Al-Qattan MM, El-Sayed AAF, Al-Zahrani AY et al. . Narakas classification of obstetric brachial plexus palsy revisited. J Hand Surg Eur Vol 2009;34:788–91. 10.1177/1753193409348185
- Duijnisveld BJ, Saraç C, Malessy MJA et al. , Brachial Plexus Advisory Board TI. Developing core sets for patients with obstetricbrachial plexus injury based on the International Classification of Functioning, Disability and Health. Bone Joint Res 2013;2:116–21. 10.1302/2046-3758.26.2000153
- Terzis JK, Kokkalis ZT. Bone discrepancy as a powerful indicator for early surgery in obstetric brachial plexus palsy. Hand (N Y) 2010;5:386–96. 10.1007/s11552-010-9270-z
- Ladak A, Morhart M, O'Grady K et al. . Distal nerve transfers are effective in treating patients with upper trunk obstetrical brachial plexus injuries: an early experience. Plast Reconstr Surg 2013;132:985e–92e. 10.1097/PRS.0b013e3182a97e13
- Verchere C, Durlacher K, Bellows D et al. . An early shoulder repositioning program in birth-related brachial plexus injury: a pilot study of the Sup-ER protocol. Hand (N Y) 2014;9: 187–95. 10.1007/s11552-014-9625-y
- Howard KA, Rogers T, Howard-Pitney B et al. . Opinion leaders’ support for tobacco control policies and participation in tobacco control activities. Am J Public Health 2000;90:1283–7. 10.2105/AJPH.90.8.1283
- Jairath N, Weinstein J. The Delphi methodology (part one): a useful administrative approach. Can J Nurs Adm 1994;7:29–42.
- Boulkedid R, Abdoul H, Loustau M et al. . Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review. PLoS ONE 2011;6:e20476 10.1371/journal.pone.0020476
- Baskett TF, Allen AC. Perinatal implications of shoulder dystocia. Obstet Gynecol 1995;86:14–17. 10.1016/0029-7844(95)00099-D
- Brouwers MC, Somerfield MR, Browman GP. A for effort: learning from the application of the GRADE approach to cancer guideline development. J Clin Oncol 2008;26:1025–6. 10.1200/JCO.2007.14.6373
- Woolf SH, Grol R, Hutchinson A et al. . Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999;318:527–30. 10.1136/bmj.318.7182.527
- Munce S, Kastner M, Cramm H et al. . Applying the knowledge to action framework to plan a strategy for implementing breast cancer screening guidelines: an interprofessional perspective. J Cancer Educ 2013;28:481–7. 10.1007/s13187-013-0490-0
- Grimshaw JM, Thomas RE, MacLennan G et al. . Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004;8:iii–iv, 1–72 10.3310/hta8060
- Akbari A, Mayhew A, Al-Alawi MA et al. . Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2008;(4):CD005471 10.1002/14651858.CD005471.pub2
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