Early Experiences and Challenges of Implementing the Sup-ER Splint Protocol for Infants with Brachial Plexus Birth Injury
Emily S. Ho, PhD, MEd, OT Reg. (Ont)1, Alison Anthony, BScPT2, Karen Klar, BScPT2, Sevan Hopyan, MD, PhD1, Howard M. Clarke, MD, PhD, FRCS(C)3 and Kristen M Davidge, MD, MSc, FRCS(C)3, (1)Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, ON, Canada, (2)Hospital for Sick Children, Toronto, ON, Canada, (3)Division of Plastic Surgery, Hospital for Sick Children, Toronto, ON, Canada
Introduction: A well-recognized challenge in the management of infants with brachial plexus birth injury (BPBI) is glenoid dysplasia and posterior subluxation of the humeral head alongside an internal rotation contracture of the shoulder. The Sup-ER splint, a repositioning program designed to position the shoulder in external rotation (ER), has the potential to address the progressive loss in passive ROM in these infants. Implementing the Sup-ER protocol requires initiation at 4 - 8 weeks of age for all infants with end-range shoulder ER tightness and/or Active Movement Scale (AMS) shoulder ER and/or supination scores < 2. The feasibility of implementing this custom labour-intensive splint and stringent protocol in clinics with large referral volumes and catchment areas has not been studied. The purpose of this study was to evaluate the feasibility of implementing the Sup-ER splint protocol.
Materials & Methods: A retrospective cohort study of infants referred to a large urban Brachial Plexus Clinic over a 3-year period was reviewed to determine the feasibility of the Sup-ER splint protocol, followed by evaluation of a modified Sup-ER protocol.
Results: Of 109 infants referred, 60 met the Sup-ER splint protocol criteria which corresponded with an average 1.69 ± 1.29 (Range 0 - 5) new referrals per month. Modifying the Sup-ER protocol by excluding infants with total plexus injury (n = 9) and those with full passive shoulder ER ROM by 3 mos (n = 36), resulted in 15 infants (13F, 2M) eligible for a modified Sup-ER protocol. The Sup-ER splint was initiated at average 3.0 ± 0.9 mos, worn 4.2 ± 1.9 mos and discontinued between 3.5 and 9.2 mos of age. Average initial shoulder ER passive ROM was 70.2 ± 9.4, and AMS ER was 2.0 ± 0.7. At a minimum of 1-year follow-up, 2 (13%) had nerve surgery and 6 (40%) had shoulder reconstruction involving glenohumeral joint reduction and tendon transfers. Of those who did not have shoulder surgery, shoulder ER passive ROM was 80.0 ± 10.0 and AMS ER was 2.3 ± 0.5 at the end of the Sup-ER protocol. Challenges with adhering to the Sup-ER protocol were related to difficulties with joint reduction associated with significant shoulder subluxation, older age at initiation of Sup-ER protocol, and poor parental/infant splint tolerance after > 6 mos of age.
Conclusions: Implementing a modified Sup-ER protocol has greater feasibility, however outcomes are negatively affected by early progression of glenohumeral dysplasia and adherence concerns.
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