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Physiotherapy

In the past, the classical goal of physiotherapy was to train the baby to use any of the functioning muscles in the affected arm. In association with that, there were exercises introduced whose goals were primarily to try to avoid the bone and joint deformities that typically develop with growth.

Today the rehabilitation program is more articulated and comprehensive.

From the first day of life, the child should have active and passive mobilization of the arm. The classical immobilization suggested in the past with the arm abducted and externally rotated is no longer being prescribed because the result were permanent and severe deformities of the shoulder joint.

The passive mobilization of the joints must be carried out not only by the hand therapist but several times a day by the parents. These maneuvers that provoke a gentle stretching of the muscles and the joint structures avoid the development of capsular contracture and the excessive contraction of the functioning muscles not contrasted by the paralysed muscles. It is of paramount importance to prevent all type of joint stiffness in order to induce, as much as possible, normal growth of the bones by maintaining correct relationships between their articular surfaces.

Direct muscular electrical stimulation seems theoretically useful to maintain the muscular trophicity as it would be the only possibility to make the paralysed muscular fibres to actively contract. Nevertheless, there is no general consensus on this treatment and there is no scientific proof of the real trophic action on the muscle fibres.  Moreover, the baby, at least in the first months of life, will not be able to tolerate the electrotherapy.

The most important step in rehabilitation is to induce, through specific passive and active movements, the creation of adequate cortical motor patterns. This program must be started very early if we want to avoid the loosening of motor patterns by the child. This is the most delicate and difficult task for the hand therapist. 

Other steps in rehabilitation program include the utilization of splints as, for instances, stabilizing the wrist in extension that will allow a stronger finger flexion to develop. 

Recently introduced, is the treatment of co-contractions with Botulin toxin. The rationale of this treatment is to temporarily paralyse a functioning muscle or muscular group in order to allow to the weak muscles in recovery to become stronger; or to allow a relaxation of muscles that maintain a strong contracture of a joint in order to facilitate the rehabilitation. 

Rehabilitation program will, of course, change as the child grows. The first  program embarked on will be performed in the hope of a possible spontaneous recovery or as a preparation for primary repair of brachial plexus. After primary surgery, the rehabilitation program will continue during the time necessary for the nerve recovery.  Afterwards, when the surgeon will identify a possible deficit which could be treated in a second time by palliative surgery, the therapist will increase the exercises targeted to improve the function of muscle transfers.  After the secondary surgery again the therapist will aid the patient to cortically integrate the new movements.

All this longstanding, rehabilitative program will continue until the complete development of the arm. We observed a substantial impairment of functional results in the patients who interrupted their rehabilitation program; that is why we strongly recommend to progressively replace the physiotherapy by swimming and other activities.