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Elbow Flexion Contractures in Obstetrical Brachial Plexus Palsy: Factors Associated with Decision to Pursue Treatment
Emily S. Ho, BSc OT Reg (Ont), Med1; Raheel Sheikh, BSc2; Howard M. Clarke, MD, PhD; FRCS(C) 1
1University of Western Ontario, London, ON, Canada, 2Hospital for Sick Children, Toronto, ON, Canada
Introduction: The prevalence of elbow flexion contractures reported in children with Obstetrical Brachial Plexus Palsy (OBPP) ranges from 48 to 85%. Children with OBPP and their families can opt to pursue a surgical or non-surgical treatment to improve the range of motion of the elbow and the cosmetic appearance of the limb. The decision to pursue treatment appears largely dependent on functional concerns and personal factors such as aesthetics and developmental age. The objective of this study was twofold: 1) Determine the clinical factors that predict whether a child with OBPP will pursue treatment for an elbow contracture and, 2) Explore the experience of young adults who had serial casting and splinting to elucidate factors associated with decisions to pursue treatment Materials and
Methods: A retrospective study of youth between 7 to 18 years who attended the authors' brachial plexus clinic in a 7-year period. The degree of contracture and functional outcome measured by the Brachial Plexus Outcome Measure (BPOM) Activity and Self-evaluation Scales were extracted from the clinic's database. In-depth interviews were conducted with a purposeful sample of 6 young adults from this sample that had non-surgical treatment as a child.
Results: 287 children were identified, 87 excluded due to missing documentation. Average age was 11.1 + 3.1 years, females (58%) and upper plexus (77%) injuries. 25% (n=50) made the decision to pursue treatment for an elbow contracture (1 surgical release, 49 serial casting/splinting). 8 declined treatment. Average degree of contracture was 23.5 + 17.5 (Range: 20-90) degrees. 13% did not have a contracture. Stepwise logistical regression model indicated that greater severity in elbow contracture, higher BPOM Activity sum score and lower BPOM Appearance Scale scores were predictive of whether a child will pursue treatment for an elbow contracture. Five main themes emerged from the interviews: 1. Functional and aesthetic reasons to pursue and continue treatment were intertwined, 2. Youths' perspective of function and appearance changed over time, 3. Splinting and casting treatment had challenges, 4. Intrinsic versus extrinsic motivation was associated with success and adherence of treatment, and 5. Early knowledge and trial of treatment were important to the youth.
Conclusions: The degree of elbow contracture, perceived satisfaction with the appearance of the limb and objective upper extremity function were predictors of whether a child will pursue treatment for an elbow contracture. Elucidating the functional and aesthetic concerns that motivate the youth to pursue treatment is important.
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