Blackwell Science, LtdOxford, UKJBRInternational Journal of Evidence-Based Healthcare1479-697X2005 The Joanna Briggs Institute322744Systematic Review Management of obstetric brachial

plexus palsyA Bialocerkowski

et al.

Int J Evid Based Healthc 2005; 3: 2744

SYSTEMATIC

REVIEW

Effectiveness of primary conservative management for infants with obstetric brachial plexus palsy
Andrea Bialocerkowski PhD MAppSc(Phty) GradDipPublicHealth,1,2,3,4 Kirsty Kurlowicz BAppSc(Phty),3 Sharon Vladusic BPhty PostGradCertPhty(Paediatrics)3 and Karen Grimmer PhD MMedSc
BPhty LMusA CertHealthEc4
School of Physiotherapy, The University of Melbourne, and 2Department of Plastic and Maxillofacial Surgery and Physiotherapy Department, Royal Childrens Hospital, Melbourne, Victoria, and 4Centre for Allied Health Evidence (a collaborating centre of The Joanna Briggs Institute), University of South Australia, Adelaide, South Australia, Australia
3 1

Executive summary
Background Obstetric brachial plexus palsy, a complication of childbirth, occurs in 1
3 per 1000 live births internationally. Traction and/or compression of the brachial plexus is thought to be the primary mechanism of injury and this may occur in utero, during the descent through the birth canal or during delivery. This results in a spectrum of injuries that vary in severity, extent of damage and functional use of the affected upper limb. Most infants receive treatment, such as conservative management (physiotherapy, occupational therapy) or surgery; however, there is controversy regarding the most appropriate form of management. To date, no synthesised evidence is available regarding the effectiveness of primary conservative management for obstetric brachial plexus palsy.

Objectives The objective of this review was to systematically assess the literature and
present the best available evidence that investigated the effectiveness of primary conservative management for infants with obstetric brachial plexus palsy.

Search strategy A systematic literature search was performed using 14 databases: TRIP,
MEDLINE, CINAHL, AMED, Web of Science, Proquest 5000, Evidence Based Medicine Reviews, Expanded Academic ASAP, Meditext, Science Direct, Physiotherapy Evidence Database, Proquest Digital Dissertations, Open Archives Initiative Search Engine, Australian Digital Thesis Program. Those studies that were reported in English and published over the last decade (July 1992 to June 2003) were included in this review.

Correspondence: Dr Andrea Bialocerkowski, School of Physiotherapy, The University of Melbourne, Melbourne, Australia. Email: aebial@unimelb.edu.au This systematic review was conducted by the Centre for Allied Health Evidence (a collaborating centre of The Joanna Briggs Institute).

Selection criteria Quantitative studies that investigated the effectiveness of primary

conservative management for infants with obstetric brachial plexus palsy were eligible for

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inclusion in this review. This excluded studies that solely investigated the effect of primary surgery for these infants, management of secondary deformities and the investigation of the effects of pharmacological agents, such as botulinum toxin.

Data collection and analysis Two independent reviewers assessed the eligibility of each study for inclusion into the review, the study design used and its methodological quality. Where any disagreement occurred, consensus was reached by discussion. Studies were assessed for clinical homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format. Results Eight studies were included in the review. Most were ranked low on the Hierarchy of Evidence (no randomised controlled trials were found), and had only fair methodological quality. Conservative management was variable and could consist of active or passive exercise, splints or traction. All studies lacked a clear description of what constituted conservative management, which would not allow the treatment to be replicated in the clinical setting. A variety of outcome instruments were used, none of which had evidence of validity, reliability or sensitivity to detect change. Furthermore, less severely affected infants were selected to receive conservative management. Therefore, it is difcult to draw conclusions regarding the effectiveness of conservative management for infants with obstetric brachial plexus palsy. Conclusions There is scant, inconclusive evidence regarding the effectiveness of
primary conservative intervention for infants with obstetric brachial plexus palsy. Further research should be directed to develop outcome instruments with sound psychometric properties for infants with obstetric brachial plexus palsy and their families. These outcome instruments should then be used in well-designed comparative studies.

Key words: birth injuries, brachial plexus neuropathies, occupational therapy, physiotherapy, rehabilitation.

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Introduction
This review addresses a distinct lack of synthesised evidence regarding the effectiveness of primary conservative management for infants (under 2 years of age) diagnosed with obstetric brachial plexus palsy (OBPP). OBPP, a complication of childbirth, occurs in 13 per 1000 live births internationally.1 This rate is comparable to that of other frequently occurring paediatric disorders, such as cerebral palsy and Downs syndrome.2,3 The prevalence of OBPP in Australia is similar to international rates.4 The Royal Childrens Hospital, Melbourne, the largest specialist paediatric centre in the Southern hemisphere, has a dedicated Brachial Plexus Registry, which contains over 200 children. Approximately 20 children are diagnosed annually and referred to the Royal Childrens Hospital Brachial Plexus Clinic for management. There are many theories regarding the aetiology of OBPP; however, traction or compression of all or part of the brachial plexus is regarded as the primary mechanism of injury.5 Traction or compression forces may be applied to the fetus in utero, during descent through the birth canal or during delivery.6 These forces may occur as a lateral torsion of the neck or as direct traction to an isolated upper limb.2 This results in a spectrum of injuries that varies in severity, extent of damage and functional use of the affected upper limb. Severity can range from neuropraxia to nerve root avulsion, with the extent of nerve injury varying from one nerve to all roots of the brachial plexus (C5T1).7 Moreover, the impact of OBPP ranges from temporary dysfunction to a lifelong functional impairment and deformity in one arm.8 Most infants receive treatment for OBPP; however, there is considerable controversy regarding the most appropriate form of primary management.9,10 This controversy is confounded by difculties in quantifying recovery due to different denitions of recovery, various outcome measures used and different timing of outcome assessment.8 Moreover, the natural recovery of OBPP is not well documented, with little scientic evidence demonstrating that active treatment is more effective compared with no treatment.11 Despite this, much anecdotal evidence suggests that most infants with OBPP receive active treatment especially during their rst 2 years of life. Active treatment could consist of exploration and or repair of the brachial plexus, or primary conservative management. Primary surgical procedures are recommended for infants who fail to improve in the rst 36 months of life.12,13

However, there is little consensus regarding criteria for surgery or the optimal timing of the surgery.7,9 This may result from limitations in clinical, imaging and electrophysiological assessments, which currently do not accurately reect the extent of damage of the brachial plexus. In addition, these assessments do not accurately predict the magnitude of expected recovery and are insensitive to detect small changes in status over time.10,14 Most infants receive primary conservative management, such as physiotherapy and occupational therapy, during their rst months of life. These therapies aim to facilitate muscle function in the infants affected upper limb and prevent complications attributed to lack of movement, such as soft tissue contractures and joint deformities. As such, primary conservative management may consist of exercise, electrotherapy and splinting.15,16 However, there is no synthesised evidence of the effectiveness of these conservative interventions. To provide the most effective primary treatment for infants diagnosed with OBPP, there is a need to determine the effectiveness of primary conservative management.

Objectives The objective of this systematic review was to systematically assess the literature and present the best available evidence of the effectiveness of primary conservative management for infants (under 2 years of age) diagnosed with OBPP. This review addressed the following questions: 1 What physiotherapy and occupational therapy interventions are used for primary conservative management? 2 What is the evidence of the effectiveness of these interventions in terms of recovery? 3 What are the characteristics of infants with OBPP who: Recover following primary conservative management? Fail to recover following primary conservative management?

Denitions The following denitions were used in this review: Infant: a child between 1 and 23 months of age.17 Primary: rst in order of time.18 Conservative management: the care and management of a patient to combat a disorder or injury, which avoids radical measures and procedures (such as surgery).18 In clinical terms, conservative management refers to therapies offered by allied health clinicians, such as physiotherapy and occupational therapy.

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Review method
Criteria for considering studies for this review Types of studies Quantitative studies that investigated the effectiveness of primary conservative management for infants with OBPP were sourced for this review. Therefore, study designs could include randomised controlled trials, pseudo-randomised controlled trials, comparative studies (cohort and case control studies) and case series. Only those studies that were reported in English and published over the last decade (July 1992 to June 2003) were sought for this review, to source the most relevant, high-quality and up-to-date evidence.19 Types of participants and interventions Participants included infants who were diagnosed with OBPP (via clinical assessment or diagnostic imaging) and were treated solely by conservative measures within the rst 2 years of life. By denition, this excluded infants who underwent primary surgery of the brachial plexus or management of secondary deformities, in addition to the investigation of the effects of pharmacological agents, such as Botulinum toxin. Types of outcomes The primary outcome for this review was recovery. Recovery could be assessed using a variety of outcome instruments that quantify impairments such as range of movement, strength and sensation. Recovery could be expressed as a change in the magnitude of the impairment(s) or classied as according rating scales which express recovery in terms of the attainment of normal function.7,10 Specic outcome instruments were not specied in this review, as there is lack of consensus regarding a gold standard outcome instrument for infants with OBPP.10,14

Search strategy Before commencing the review, the Cochrane Library, Joanna Briggs Institute website and Database of Abstracts of Review of Effectiveness were searched to ensure that a similar review had not previously been published or was currently being undertaken. No such reviews were found. Our search strategy was developed so that it was systematic (could be replicated independently) and identied published and unpublished studies. Eleven databases were searched to identify as much of the published literature as possible. These included TRIP, MEDLINE, CINAHL, AMED, Web of Science, Proquest 5000, Evidence Based Medicine Reviews, Expanded Academic ASAP, Meditext, Science

Direct and the Physiotherapy Evidence Database (PEDro). All were available through The University of Melbourne library, except for the TRIP database and PEDro, which were accessed via the internet. Three additional databases, which were available via The University of Melbourne library, were searched to identify theses on this topic (Proquest Digital Dissertations, Open Archives Initiative Search Engine (myOAI), the Australian Digital Thesis program (ADP)). As each database has their own indexing terms and search functions, search strategies were developed for each database. Databases were rst classied into three groupings based on their search function characteristics: Group 1: databases where papers are classied according to their Medical Subject Headings and key terms, and which had functions that allowed terms to be combined (MEDLINE, CINAHL, AMED). Group 2: databases where key terms are used to classify papers and have limited ability to combine key terms (Web of Science, Expanded Academic ASAP, Proquest 500, Meditext, Evidence Based Medicine Reviews). Group 3: databases where only one key term could be searched (Science Direct, PEDro, myOAI, ADT, TRIP database). Second, during the development of the search strategy, consideration was given to the terminology used to describe OBPP and conservative management, as this could inuence the identication of relevant studies. Search strategies were then developed for each database groupings according to strategies outlined by Brettle and Grant:20 Group 1: key words describing OBPP and conservative treatment were mapped to the Medical Subject Heading. Both the Medical Subject Heading and key words were used in the search using appropriate combining terms (AND or OR). As MEDLINE, CINAHL and AMED use different Medical Subject Headings, individualised search strategies were developed for each database. Appropriate truncation symbols were used. Group 2: key words used to describe OBPP were combined using the OR function. Where available, truncation symbols were used. Group 3: a single term, obstetric brachial plexus palsy, was entered into the database. The specic search strategies for each database are provided in Appendix I. Our search strategy also included secondary searching, such as reviewing reference lists of the included papers. Hand searching or contacting experts in the eld were not employed in this review, as these methods are difcult to undertake systematically and therefore replicate. In addition,

Management of obstetric brachial plexus palsy

31

it was likely that all journals in which this work was published would be indexed in the 14 databases searched. Assessment of methodological quality The studies identied from the searching process were independently assessed by two reviewers against the inclusion criteria (type of study, participants, outcomes) (Appendix II). The full text version of all relevant studies was obtained. In addition, where there was insufcient information available in the title and abstract to judge the papers suitability for inclusion into the study, the full text version of the paper was also retrieved for further analysis against the inclusion criteria. Inclusion of studies into this review was reached by consensus between the reviewers. All references were entered into a Microsoft Excel (1998) database. Each study was critically appraised by determining: Level on the NHMRC Hierarchy of Evidence.21 This determines the magnitude of bias within each study design.21 Methodological quality of the study, using the Critical Review Form Quantitative Studies by Law et al.22 (Appendix III). This critical appraisal tool evaluates the internal and external validity of a study and its ndings.22 The advantages of this critical appraisal tool are that it can be used for all types of quantitative studies, and has an accompanying document that provides guidelines for use.23 This allows for standardised interpretation of its items. To provide a snap shot of the overall quality of each study, the closed ended questions on the Critical Review Form were scored as either a 1 (completely fulls the criterion) or 0 (does not full the criterion). The scores for the 16 closed ended questions were tallied to produce a total score indicating overall quality of the study. The maximum score of 16 indicated excellent quality. A description of all of the included studies was then undertaken, and contained information regarding the: study participants, including the method of diagnosis of OBPP; description of the treatment and control interventions; main results, including the effectiveness of primary conservative management for infants with OBPP and identication of characteristics of infants who recover and those who fail to recover with conservative primary management; outcome measures, including the type and time of use. Both reviewers extracted this information independently. Where any disagreement occurred between reviewers, consensus was reached by discussion. The studies were assessed for clinical homogeneity by considering the populations, interventions and outcomes.

Where heterogeneity was present, synthesis was undertaken in a narrative format.

Results
Description of studies The extensive search strategy yielded 411 hits. After the removal of duplicate titles and those that did not meet the inclusion criteria, the full text version of 24 papers was reviewed. Of these, 16 were excluded as they did not meet the inclusion criteria (Appendix IV). Therefore, this systematic review is an analysis of eight studies,2431 which were conducted in the UK, USA, Turkey, Switzerland, Finland, Sweden and China. There was 100% agreement between the reviewers for the studies included in this review. Critical appraisal Hierarchy of evidence There was 100% agreement between the reviewers regarding the types of study designs used in the included studies. Three of the eight studies were comparative in nature, in that they evaluated the effect of conservative management against surgical intervention26,30,31 (Appendices V,VI). Surgery consisted of exploration only,26 nerve transfer/grafting,26,30,31 internal neurolysis and or neuroma excision,26 or neurolysis alone31 (Appendix V). As there was no randomisation of infants into treatment groups, these studies are classied as III-2 on the NHMRC Hierarchy of Evidence.20 The remaining studies (n = 5) were case series (Level IV),24,25,2729 as the status of the infant was assessed before and after conservative management but not compared with another intervention (Appendix VI). Both of these study designs contain signicant inherent sources of bias, which need to be considered when interpreting the authors results. Methodological quality There was 98% agreement between the reviewers regarding the methodological quality of the included studies. The methodological quality of the studies was fair, with the average score being 8.5 from a total of 16 (SD = 1.2). Strombeck et al.30 produced the highest quality study, with a score of 11, whereas the lowest score range was 727 (Appendix VI). All studies fullled criteria 5, 13 and 15 (Appendix VII). The sample was described in detail with respect to demographic characteristics (Criterion 5); however, little information was provided regarding the criteria for diagnosis of OBPP. All authors provided a discussion of the clinical importance of the results (Criterion 13) and related this to implications for clinical practice (Criterion 15).

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Although seven of the eight authors provided a justication of their sample size,2430 this was based on pragmatic terms (data collected during a specic time period) and not by statistical means (sample size calculation or post hoc power analysis). None of the studies met Criteria 4, 8, 9 and 10 (Appendix VII). There were biases present in all of the studies reviewed (Criterion 4). These included co-intervention (some surgical candidates received physiotherapy), lack of blinding of the assessor (the assessor had knowledge of the treatment the infant received) and selection bias (the surgical group had a more severe lesion compared with infants in the conservative group). None of the outcome measures used to evaluate change over time were reported as either valid or reliable (Criteria 8 and 9, respectively) and none of the interventions were described in detail to allow replication (Criterion 10). Moreover, less than half of the authors used appropriate statistical analysis (Criterion 12), reported their results in terms of statistical signicance (Criterion 11) or acknowledged the limitations of their study (Appendix VII). Therefore, the results of all studies should be interpreted with caution. Participants Infants with OBPP were generally assessed within the rst 3 months of life at a specialist paediatric unit.24,26,27,29,30 There was a lack of information regarding the procedure(s) used to diagnose OBPP, with only four authors providing this information2629 (Appendix V). Therefore, it is not known whether a homogeneous sample of participants was recruited across the eight studies. Types of interventions All participants received solely conservative management within the rst 2 years of their lives. Conservative management could consist of: gentle regular exercises;24 passive range of movement, developmental and strengthening exercises;25 active and passive movement;26 dynamic traction;28 home exercise program;27,30 splints.25 In addition, four authors described conservative management in more general terms, such as occupational therapy,29 physiotherapy,26,29 or conservative treatment30,31 (Appendix V). However, the description of the treatment used was often brief, and lacked information regarding the specic modalities or exercises utilised and their dosage (repetitions, frequency, duration).

Effectiveness of interventions Recovery rates for primary conservative management ranged from 17%25 to 100%26,27 with most studies reporting attainment of normal or near normal function in over 80% of the sample.24,2629,31 There was conicting evidence regarding the relative effectiveness of primary conservative management compared with surgery for infants with OBPP (Appendix VI). Laurent et al.26 reported a greater recovery rate in those children managed conservatively compared with those who received surgical management (100% recovery compared with 90% recovery). This was determined by quantifying triceps, deltoid and biceps function, using the British Medical Research Councils Muscle Movement Scale.14 In contrast, Strombeck et al.30 reported that infants who were managed surgically (primary exploration of the brachial plexus) had on average 30% more active shoulder movement compared with those that were managed conservatively. Range of motion was classied on a 0 3 scale (0 = no movement, 1 50% movement, 2 50% movement but not full range, 3 = normal movement), for ve directions of movement: extension, exion, abduction, internal and external rotation. Scores for each direction of movement were tallied, and converted into a percentage. Strombeck et al.s30 nding is in agreement with that of Xu et al.31 who reported that 70% of infants who underwent nerve transfer/grafting had good to excellent recovery compared with 0% in the conservatively managed group, as measured by the Mallet Scale. This scale quanties (on a ve-point scale) the infants ability to perform ve upper limb movements: shoulder abduction, external rotation, hand to mouth, hand to nape of the neck, and hand behind back10 (Appendix VIII). Characteristics of infants who recovered Lindell-Iwan et al.28 and Strombeck et al.30 used an anatomic classication to group infants in terms of the severity of the brachial plexus lesion.6 Lindell-Iwan et al.28 suggested that most infants with minor lesions (C5 and C6) recover in less than 1 month following birth, with conservative management. This is in contrast to Strombeck et al.30 who found that children with C5 and C6 lesions gained signicantly greater active shoulder range of movement with surgical intervention compared with those who were managed conservatively. These authors used different outcome instruments to quantify recovery. Characteristics of infants who failed to recover There was little evidence regarding infants who failed to recover with conservative intervention. Lindell-Iwan et al.28 were the only authors to document the relationship

Management of obstetric brachial plexus palsy

33

between severity of brachial plexus lesion (using an anatomical model) and outcome. However, this was not related to evaluating the effectiveness of conservative management. Outcomes Seven of the eight authors used outcome instruments that were specically developed for infants with OBPP or for older children/adults with peripheral nerve lesions.2429,31 Various instruments were used and they differed with respect to: The variables that were quantied. Outcome instruments could solely assess muscle strength or active movement, or could combine the results of a number of variables (such as strength, active movement, sensation, scapular position) to produce a single score. The area of assessment. Outcome instruments could focus on a specic upper limb joint, such as the shoulder or elbow, or could assess the function of muscle groups or the whole upper limb (Appendix VIII). The most frequently used outcome instruments were the Mallet Scale (shoulder function)24,27,31 and the British Medical Research Councils Muscle Movement Scale.26,28 However, difculty exists when attempting to combine the results of the studies even when the same outcome measures were used. The Mallet Scale is recommended for children who can follow instructions (approximately 4 years of age).10,32 Given that Bisinella and Birch24 and Leblebicioglu et al.27 conducted their assessment well before this age, the precise methodology that was used was not detailed. Although Laurent et al.26 and Lindell-Iwan et al.28 both used the British Medical Research Councils Muscle Movement Scale, different muscle groups were assessed. This makes it difcult to combine the results of studies in a meta-analysis. In addition, our results indicate the large variation in outcome instruments used to assess infants with OBPP and the potentially different procedures used to administer them. As such, there appears to be no gold standard outcome instrument for infants with OBPP. Only one author assessed impairment variables that are frequently documented in children with other upper limb disorders.30 These variables included active joint movement, tactile sensibility, pickup test, grip strength, ability to grip and bimanual activities. Detailed descriptions of the assessment protocols were provided by this author, but were not compared with norms. The time of assessment was also variable between authors (Appendix V) and ranged from 12 months26 to 5 years of age.30 In general, this information was either not reported in detail24,27,29,30 or omitted from the publication.25,28,31 Laurent et al.26 provided the most detailed description of the time of outcome assessment, which tracked status over a 1-

year period (at 2, 4, 9 and 12 months of age). Thus scant information was provided regarding the end point of these studies. The end point of studies is important to dene, as improvement in infants with OBPP can be a long and slow process.11 Moreover, the lack of this information makes it difcult to combine the results of studies using methods other than narrative format. The psychometric properties of the outcome instruments used were not stated by any of the authors. Therefore, it is not known whether the outcome instruments were valid, reliable or sensitive to detect signicant change over time, in infants with OBPP. This information is vital when interpreting the effectiveness of interventions, as the selected outcome instrument should measure the construct(s) of interest, and detect change in clinical status that is greater than measurement error.33 Because this information was lacking in all papers reviewed, irrespective of the outcome instrument used, the results of these studies need to be interpreted with caution.

Discussion
This is the rst systematic review that has collated evidence regarding the effectiveness of conservative management for infants with OBPP. Our search strategy was both systematic and thorough, whereby primary and secondary searches were undertaken to locate published and unpublished evidence.34,35 We are condent that we have located the majority of evidence on this topic, although our search strategy did not include hand searching and contacting experts in the eld. These additional searching strategies are difcult to undertake in a systematic manner and therefore difcult to replicate. In addition, it was likely that all journals in which this work was published would be indexed in the 14 databases searched. The search strategy was limited to papers published in English during the last decade. Date limits were set, as Maher et al.19 suggest that the methodological quality of studies has increased over time, especially since the mid-1990s. Although only English language papers were included in this study, we planned to record evidence, on this topic, which was published in other languages. However, none were found. A limitation of this systematic review is that the reviewers were not blinded to the author or source of the paper. Although this may affect the rating of methodological quality, consistent results were independently gained from both of the reviewers. The heterogeneous nature of the studies prevents the results from being pooled in a meta-analysis.34,35 Conse-

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quently the results were presented in a narrative summary (with detailed results in Appendix VII). Physiotherapy and occupational therapy interventions Our review found that physiotherapy and occupational therapy are used as primary conservative management for infants with OBPP. Treatment could consist of: gentle regular exercise for the prevention of xed deformities;23 passive range of movement;25,28 active movement;28 developmental exercises;25 strengthening exercises;25 splints;25 dynamic traction;28 physiotherapy.26,27 All studies lacked a clear description of what constituted conservative management. As such, this would not allow replication of the treatment in the clinical setting. Most treatments were provided as a package of care, whereby treatments were combined within a session.36 Although it was not the intent of any of the authors to determine the most effective intervention or combination of interventions for children with OBPP, it is difcult to conclude which treatments should be used in combination or isolation. Moreover, no authors provided a theoretical justication of the treatment package they evaluated. In the clinical setting, physiotherapists and occupational therapists use a variety of treatment techniques to treat infants with OBPP. These include the techniques listed above in addition to others such as: neuromuscular electrical stimulation;16,37,38 joint mobilisation;16 postural re-education;16 myofascial release;16 heat;16 biofeedback;38 skin and joint protection;39 sensory retraining;16 functional retraining.15 Although there is anecdotal evidence to suggest that these other techniques are useful when treating infants with OBPP, we were unable to nd studies that evaluated their effectiveness. Thus, there appears to be a mismatch between the techniques used in clinical practice and those that have been evaluated scientically. In order to justify the use of these additional techniques, research is required to determine their effectiveness.

Effectiveness of interventions It seems that conservative management could be effective in infants with OBPP. However, it was not possible to determine the relative effectiveness of primary conservative management compared with surgery for infants with OBPP, because of conicting results. Laurent et al.26 found that conservative management was more effective than surgery, whereas surgery was found to be the more effective treatment by Strombeck et al.30 and Xu et al.31 This discrepancy in these results could be explained by a number of factors, which are linked to methodological quality. Different outcome instruments were used by each author. Each of these instruments has different measurement scales which may not have been adequately sensitive to capture change over time. Moreover, there was no evidence of validity or reliability of any of these outcome instruments or the magnitude of measurement error. The only OBPP outcome instrument that has documented evidence of reliability, although moderate,10,14 is the Active Movement Scale.40 This instrument was not used in any study in this systematic review. The second factor that could inuence the results of the studies was selection bias. All infants who received conservative intervention were less severely affected compared with those who underwent surgery. In fact, the decision to operate was based on recovery or failure to improve in the rst 6 months of life. However, the denitions used for recovery and the criteria for surgery were scant, with only one author describing recovery based on the change observed on an outcome measure (change in one category on the British Medical Research Councils Muscle Movement Scale).26 Given that a difference in groups existed at baseline, it is difcult to draw conclusions regarding the most effective treatment without adjustments for these variables. These adjustments were not made by any of the authors and few acknowledged that this could potentially affect results. Most of the studies in this review were case series, and selection bias may have resulted from anecdotal evidence which suggests that more severely affected infants gain greater recovery from surgical intervention rather than from conservative treatment. However, in a recent systematic review, it was found that there is no high-quality evidence which supports the use of primary surgery to the brachial plexus for infants with OBPP.41 Furthermore, the natural history of OBPP is not known,11 and a comparison between the effectiveness of conservative management and no intervention has not been undertaken. Infants were followed for various periods of time to determine the effectiveness of conservative interventions. How-

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ever, no justication for these time periods was provided. Pondaag et al.11 suggested that outcome of primary treatment should be assessed after the child reaches 3 years of age. Recovery could take up to 3 years, neurological investigation in infants is hard to quantify compared with that in children, and functional disabilities caused by OBPP may only become apparent when children increase the complexity of tasks performed, such as dressing and feeding. However, only two authors quantied the status of OBPP in children over 3 years of age and neither provided a justication for this decision.30,31

Characteristics of infants who recover Because of methodological problems in the evidence, it was not possible to determine the characteristics of children who recover with conservative management as their primary treatment. This may well explain the conicting evidence gained from Lindell-Iwan et al.28 and Strombeck et al.30 Strombeck et al.s study30 was cross-sectional in nature, with children being assessed on average at the age of 5 years. Although the sample was stratied according to the severity of the lesion (level of the brachial plexus lesion) at the time of the study, these criteria may not have been used to determine the suitability of the child for primary surgical management. Strombeck et al.30 stated there has been a resurgence of interest in surgical intervention during the last two decades, with many changes in criteria used to determine the suitability of primary exploration of the brachial plexus. In contrast, Lindell-Iwan et al.28 gained their results from a retrospective case series review. This type of methodology has many sources of bias (such as no comparison group, no assessor blinding and the potential for co-intervention) and lack of standardised assessment and treatment protocols (because potentially many different clinicians could assess and treat the infant). Characteristics of infants who fail to recover There was little evidence regarding infants who failed to recover with conservative intervention. This is perhaps because surgery was offered to those infants who showed little or no recovery within the rst 6 months of life.

limb and prevent joint contractures and secondary joint deformities.1,5,15,42 However, despite conservative management being routine in many OBPP clinics internationally, there is little evidence to support this approach. There has been little research conducted in this area, as evidenced by the small number of studies that were found. This is in contrast to research that has been conducted in other areas of OBPP. For example, Pondaag et al.11 found 32 studies that met their inclusion criteria with regards to the natural history of OBPP. We used an extensive research strategy (many databases and various search terms) and thus we are condent that we identied most of the evidence on this topic. The results of this systematic review indicate that it is difcult to draw conclusions regarding the effectiveness of conservative management or to determine the characteristics of infants who best respond to conservative management because of the generally poor methodological quality of the papers, as evidenced by the use of a variety of outcome instruments, their lack of psychometric properties, variable assessment times, selection of less severe infants to receive the conservative management and lack of a comparison group. Thus, clinicians cannot seek guidance from the evidence regarding the effect of conservative intervention and our ndings provide a justication for future research in this area. Implications for research The results of this review highlight the need for further research to determine the effectiveness of primary conservative management for infants with OBPP, so that these interventions can be justied. However, to achieve this, outcome instruments with sound psychometric properties must be used to accurately document change over time.42 To date, OBPP outcome instruments that are valid, reliable and sensitive to detect change do not exist. Moreover, outcome instruments should measure variables of interest or importance to the clinicians who are using them and the families of infants with OBPP.43 It appears that most OBPP outcome instruments were developed by surgeons. Thus, their items may not measure important therapy- or family-orientated variables, such as developmental milestones and compliance with home exercise programs. Future research should focus on the development of more appropriate outcome instruments, with sound psychometric properties, for this population. Our results highlight that most of the studies in this review were undertaken by surgeons or physicians, with little involvement with physiotherapists or occupational

Conclusions
Implications for practice Primary conservative management (physiotherapy and occupational therapy) is a well-established form of treatment of infants with OBPP. The rationale for this management is to facilitate active movement or strength of the affected upper

36

A Bialocerkowski et al. 6. Dodds SD, Wolfe SW. Perinatal brachial plexus palsy. Curr Opin Pediatr 2000; 12: 407. 7. Birch R. Obstetric brachial plexus palsy. J Hand Surg 2002; 27B: 38. 8. van Dijk JG, Pondaag W, Malessy MJ. Obstetric lesions of the brachial plexus. Muscle Nerve 2001; 24: 145161. 9. Grossman JAI, Ramos LE, Shumway S, Alfonso I. Management strategies for children with obstetrical brachial plexus injuries. Int Pediatr 1997; 12: 826. 10. Bae DS, Waters PM, Zurakowski D. Reliability of three classication systems measuring active motion in brachial plexus birth palsy. J Bone Joint Surg 2003; 85A: 17338. 11. Pondaag W, Malessy MJA, Thomeer RTWM. Natural history of obstetrical plexus palsy: a systematic review. Dev Med Child Neurol 2004; 46: 13844. 12. Waters PM. Comparison of the natural history, the outcome of microsurgery and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone Joint Surg 1999; 81A: 649 59. 13. Marcus JR, Clarke HM. Management of obstetrical brachial plexus palsy: evaluation, prognosis and primary surgical treatment. Clin Plast Surg 2003; 30: 289306. 14. Curtis C, Stephens D, Clarke H, Andrews D. The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy. J Hand Surg 2002; 27A: 4708. 15. Van Ouwerkerk WJR, van der Sluijs JA, Nollet R, Barkhof F, Slooff ACJ. Management of obstetric brachial plexus lesions: state of the art and future developments. Childs Nerv Syst 2000; 16: 63844. 16. Ramos LE, Zell JP. Rehabilitation program for children with brachial plexus and peripheral nerve injury. Semin Pediatr Neurol 2000; 7: 527. 17. National Library of Medicine. Available from: http:// www.nlm.nih.gov/mesh/meshhome.html (accessed 2 June 2004). 18. Mosbys Medical Nursing and Allied Health Dictionary, 6th edn. St Louis: Mosby, 2000. 19. Maher C, Moseley A, Sherrington C, Herbert R. Core journals of evidence-based physiotherapy practice. Physiother Theory Pract 2001; 17: 14351. 20. Brettle A, Grant MJ. Finding the Evidence for Practice: A Workbook for Health Professionals. Edinburgh: Churchill Livingstone, 2004. 21. National Health and Medical Research Council. How to Use the Evidence: Assessment and Application of Scientic Evidence. Canberra: National Health and Medical Research Council, 2000. 22. Law M, Stewart D, Letts L, Pollock N, Bosch J, Westmorland M. Critical Review Form Quantitative Studies. Available from: http://www.cotfcanada.org/cotf_critical.html (accessed 2 June 2004). 23. Katrak P, Bialocerkowski AE, Massy-Westropp N, Kumar VSS, Grimmer KA. A systematic review of critical appraisal tools. BMC Med Res Methodol 2004; 4: 22. Available from: http:// www.biomedcentral.com/147-2288/4/22 (accessed 27 October 2004). 24. Bisinella GL, Birch R. Obstetric brachial plexus lesions: a study of 74 children registered with the British paediatric surveillance unit (March 1998March 1999). J Hand Surg 2003; 28B: 405. 25. Eng GD, Binder H, Getson P, ODonnell R. Obstetrical brachial plexus palsy (OBPP) outcome with conservative management. Muscle Nerve 1996; 19: 88491.

therapists.2426,28,29,31 The treatment of infants with OBPP is multidisciplinary,40 with physiotherapists and occupational therapists playing a signicant role in the management. Thus, physiotherapists and occupational therapists need to take responsibility for documenting and publishing the outcome of their management, in order to justify the treatment that they provide.

Acknowledgements
The authors would like to thank the Joanna Briggs Institute for funding this research. This research has also been supported by a National Health and Medical Research Council Health Professional Training Fellowship for Dr Andrea Bialocerkowski. Appreciation goes to Professor Joan McMeeken (Head, School of Physiotherapy, The University of Melbourne, Melbourne), Professor John Meara (Director, Department of Plastic and Maxillofacial Surgery, Royal Childrens Hospital, Melbourne) and Ms Anne McCoy (Honorary Physiotherapist, Physiotherapy Department, Royal Childrens Hospital, Melbourne) for their support for this project. The authors would like to thank the following individuals for their assistance with reviewing this report: Professor Mary Galea, Foundation Professor of Clinical Physiotherapy, at the University of Melbourne, based at Austin Health, Melbourne; Professor John Meara, Director, Department of Plastic and Maxillofacial Surgery at the Royal Childrens Hospital, Melbourne; Dr Bruce Johnstone, Deputy Director, Department of Plastic and Maxillofacial Surgery at the Royal Childrens Hospital, Melbourne; Dr David McCoombe, Department of Plastic and Maxillofacial Surgery at the Royal Childrens Hospital, Melbourne; Ms Anne McCoy, Honorary Physiotherapy Department, Royal Childrens Hospital, Melbourne.

References
1. Dunham EA. Obstetrical brachial plexus palsy. Orthopaed Nurs 2003; 22: 10616. 2. Shenaq S, Kim JYS, Armenta AH, Nath RK, Cheng E, Jedrysiak A. The surgical treatment of obstetric brachial plexus palsy. Plast Reconstr Surg 2004; 113: 5467. 3. Slooff ACJ. Obstetric brachial plexus lesions and their neurosurgical treatment. Microsurgery 1995; 16: 304. 4. Bates D, Bartlett J, Meara JG et al. The natural history of obstetric brachial plexus palsy: a 10-year experience. Plast Reconstr Surg (in press). 5. Kay SPJ. Obstetrical brachial palsy. Br J Plast Surg 1998; 51: 43 50.

Management of obstetric brachial plexus palsy 26. Laurent JP, Lee R, Shenaq S, Parke JT, Solis IS, Kowalik L. Neurosurgical correction of upper brachial plexus birth injuriese. J Neurosurg 1993; 79: 197203. 27. Leblebicioglu G, Leblebicioglu D, Tugay N, Atay OA, Gogus T. Obstetrical brachial plexus palsy: an analysis of 105 cases. Turkish K Pediatr 2001; 43: 1819. 28. Lindell-Iwan H-L, Partanen VSL, Makkonen M-L. Obstetric brachial plexu palsy. J Pediatr Orthop 1996; 5B: 21015. 29. Noetzel MJ, Park TS, Robinson S, Kaufman B. Prospective study of recovery following neonatal brachial plexus injury. J Child Neurol 2001; 16: 48892. 30. Strombeck C, Krumlinds-Sundholm L, Forssberg H. Functional outcome at 5 years in children with obstetrical brachial plexus palsy with and without microsurgical reconstruction. Dev Med Child Neurol 2000; 42: 14857. 31. Xu J, Chend X, Gu Y. Different methods and results in the treatment of obstetrical brachial plexus palsy. J Reconstr Microsurg 2000; 16: 41722. 32. Basheer H, Zelic V, Rabia F. Functional scoring system for obstetric brachial plexus palsy. J Hand Surg 2000; 25B: 41 5. 33. Beatie P. Measurement of health outcomes in the clinical setting: applications to physiotherapy. Physiother Theory Pract 2001; 17: 17385.

37

34. Anderson CM, Overend TJ, Lucy SH. Changing practice through a systematic review: reections from experience. Physiotherapy Canada 2002; Summer: 186198. 35. Stevens KR. Systematic reviews: the heart of evidence-based practice. AACN Clin Issues 2001; 12: 52938. 36. Grimmer K, Bowman P, Roper J. Episodes of allied health outpatient care: an investigation of service delivery in acute public hospital settings. Disabil Rehab 2000; 22: 807. 37. Nelson MR. Birth brachial plexus palsy. Phys Med Rehabil State Art Rev 2000; 14: 23746. 38. Tersis JK, Papakonstantinou KC. Management of obstetrical brachial plexus palsy. Hand Clin 1999; 15: 71737. 39. Mulloy EM, Ramos LE. Special rehabilitation considerations in the management of obstetrical brachial plexus injuries. Hand Clin 1995; 11: 61922. 40. Clarke HM, Curtis CG. An approach to obstetrical brachial plexus injuries. Hand Clin 1995; 11: 56381. 41. McNeely PD, Drake JM. A systematic review of brachial plexus surgery for birth-related brachial plexus injury. Pediatr Neurosurg 2003; 38: 5762. 42. Andresen EWM. Criteria for assessing the tools of disability outcomes research. Arch Phys Med Rehabil 2000; 81: S1520. 43. Bowling A. Research Methods in Health: Investigating Health and Health Services. Buckingham: Open University Press, 1997.

Appendix I
Search strategy MEDLINE 1 2 3 4 5 brachial plexus neuropathies/ birth injuries brachial plexus 2 and 3 (erb$ palsy or brachial plexus palsy or Klumpke palsy) m.p. [mp=title, original title, abstract, name of substance mesh subject heading] 5 or 6 exercise movement techniques/ treatment outcome/ occupational therapy splints/ electric stimulation rehabilitation/ 8 or 9 or 10 or 11 or 12 or 13 (exercise program$ or active movement or passive movement or stretch$ or neuromuscular electrical stimulation or treatment) m.p. [mp=title, original title, abstract, name of substance mesh subject heading] 14 or 15 7 and 16 limit 18 to (English and yr=19922003) CINAHL 1 2 3 4 5 brachial plexus neuropathies/ birth injuries brachial plexus 2 and 3 (erb$ palsy or brachial plexus palsy or Klumpke palsy) m.p. [mp=title, cinahl subject headings, abstract, instrumentation] 5 or 6 physical therapy/ treatment outcomes/ occupational therapy splints/ electric stimulation rehabilitation, pediatric/ 8 or 9 or 10 or 11 or 12 or 13 (exercise program$ or active movement or passive movement or stretch$ or neuromuscular electrical stimulation or treatment) m.p. [mp=title, cinahl subject headings, abstract, instrumentation) 14 or 15 7 and 16 limit 18 to (English and yr=19922003)

6 7 8 9 10 11 12 13 14

6 7 8 9 10 11 12 13 14

15 16 17

15 16 17

38

A Bialocerkowski et al.

AMED 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 brachial plexus/ infant 1 and 2 infant newborn disease/ 3 or 4 (erb$ palsy or brachial plexus palsy or Klumpke palsy) m.p. [mp=abstract, heading words, title] 5 or 6 treatment outcomes/ exercise/ physiotherapy/ rehabilitation/ splints/ occupational therapy/ functional electric stimulation/ 8 or 9 or 10 or 11 or 12 or 13 or 14 (exercise program$ or active movement or passive movement or stretch$ or neuromuscular electrical stimulation or treatment) m.p. [mp=abstract, heading words, title] 15 or 16 7 and 17 limit 18 to (yr=19922003)

Web of Science, Evidence Based Medicine Reviews 1 2 3 4 brachial plexus palsy erb* palsy obstetric* palsy #1 or #2 or #3

Meditext 1 2 3 4 brachial plexus palsy erb* palsy obstetric* palsy #1 or #2 or #3

Expanded Academic ASAP, Proquest 5000 1 2 3 4 brachial plexus palsy erbs palsy obstetrical palsy #1 or #2 or #3

Science Direct, Physiotherapy Evidence Database, Proquest Digital Dissertations, myOAI, ADT, TRIP database 1 obstetric brachial plexus palsy

17 18 19

Appendix II
CITATION Title Journal Volume (issue): pages Numbers Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Quantitative Published 19922003 English OBPP Infants Primary conservative Mx TYPE OF STUDIES PARTICIPANTS OUTCOMES Functional recovery Yes/No

Verication of study eligibility

Authors

Publication date Text Text

Text

(Year)

Appendix III

Critical Appraisal Form

The Critical Appraisal Form Quantitative Studies22 and guidelines for use can be found on http://www.cotfcanada.org/cotf_critical.htm. Information answering these questions was entered into a Microsoft Excel (1998) spreadsheet, as detailed below.
LITERATURE REVIEW Relevant Yes = 1, No = 0 Justication Text Study design Text DESIGN Appropriate Yes = 1, No = 0 Biases present Yes = 1, No = 0 List biases Text

AUTHOR Purpose Text

STUDY PURPOSE

Clearly stated

Management of obstetric brachial plexus palsy

Yes = 1, No = 0

39

AUTHOR 40 Sample size justied Sample characteristics Text Text Yes = 1, No = 0 Text Yes = 1, No = 0 Yes = 1, No = 0 Diagnosis of OBPP Informed consent gained Instruments Reliable Valid

SAMPLE

OUTCOMES

Described in detail

A Bialocerkowski et al.

Yes = 1, No = 0

Yes = 1, No = 0

AUTHOR Intervention Text Yes = 1, No = 0 Yes = 1, No = 0 Statistical signicance reported Appropriate analysis

INTERVENTION

RESULTS Clinical importance reported Yes = 1, No = 0

CONCLUSIONS Appropriate Yes = 1, No = 0 Conclusions Text

Described in detail

Yes = 1, No = 0

AUTHOR Reported Yes = 1, No = 0

CLINICAL IMPLICATIONS Limitations reported Yes = 1, No = 0 Limitations Text

Management of obstetric brachial plexus palsy

41

Appendix IV
Excluded studies 1. Al-Qattan MM. Obstetric brachial plexus palsy. J Am Soc Surg Hand 2003; 28: 405. Reason for exclusion: Review article. 2. Birch R. Obstetric brachial plexus palsy. J Hand Surg 2002; 27B: 38. Reason for exclusion: Editorial. 3. Dodds SD, Wolfe SW. Perinatal brachial plexus palsy. Curr Opin Pediatr 2000; 12: 407. Reason for exclusion: Review article. 4. Dunham EA. Obstetrical brachial plexus palsy. Orthop Nurs 2003; 22: 10616. Reason for exclusion: Review article. 5. Ferraresi S, Garozzo D, Grifni C et al. Brachial plexus injuries. Guidelines for management: our experience. Italian J Neurological Studies 1994; 15: 27284. Reason for exclusion: Review article. 6. Harris SL, Wood KW. Resolution of infantile erb palsy utilizing chiropractic treatment. J Manipulative Physiol Ther 1993; 16: 4158. Reason for exclusion: Single case study. 7. Kay SP. Obstetrical brachial palsy. Br J Plast Surg 1998; 51: 4350. Reason for exclusion: Review article. 8. Manwani S, Hosain SA. Outcome of perinatal brachial plexus palsy. Ann Neurol 2000; 48: 515. Reason for exclusion: No statement regarding the treatment received. 9. Marcus JR, Clarke HM. Management obstetrical brachial plexus palsy: evaluation prognosis and primary surgical treatment. Clin Plast Surg 2003; 30: 289306. Reason for exclusion: Review article. 10. McNeeley PD, Drake JM. A systematic review of brachial plexus surgery for birth-related brachial plexus injury. Pediatr Neurosurg 2003; 38: 5762. Reason for exclusion: This paper was a systematic review that did not primarily address the effectiveness of conservative intervention for OBPP. However, the reference list was reviewed to source any papers that compared the effectiveness of surgical intervention with conservative treatment for OBPP. 11. Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF. The natural history of obstetrical brachial plexus palsy. Plast Reconstr Surg 1994; 93: 67580. Reason for exclusion: The authors document the natural history of OBPP, without mention of whether this includes conservative treatment. 12. Nelson MR. Birth brachial plexus palsy. Phys Med Rehabil State Art Rev 2000; 14: 23746 Reason for exclusion: Review article. 13. Ramos LE, Zell JP. Rehabilitation program for children with brachial plexus palsy. Semin Pediatr Neurol 2000; 7: 527. Reason for exclusion: Review article. 14. Shenaq SM, Berzin E, Lee R, Laurent JP, Nath R, Nelson MR. Brachial plexus birth injuries and current management. Clin Plast Surg 1998; 25: 52736. Reason for exclusion: Review article. 15. Terzis JK, Papakonstanhtinou KC. Management of obstetric brachial plexus palsy. Hand Clin 1999; 15: 717 36. Reason for exclusion: Review article. 16. 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 1999; 81A: 649. Reason for exclusion: The authors document the natural history of OBPP, without mention of whether this includes conservative treatment.

Appendix V
42 Participants Sample characteristics None Surgery for brachial plexus exploration if no clinical recovery of biceps by 3/12 (n = 9) Passive ROM, developmental and strengthening exercises, splints (n = 191) Surgery: those who did not improve by 4/12 (n = 24): Physiotherapy: those that did improve by 4/12 (n = 88) British Medical Council movement scale for deltoid, biceps, triceps (Improvement = change in one category in two muscle groups) Mallet classication, Gilberts criteria Not applicable Impairment rating Not stated Gentle regular exercises for the prevention of xed deformities (n = 51) Mallet Scale, Gilbert Scale, Gilbert and Raimondi Scale, Raimondi system Diagnostic criteria Treatment Control Outcome instruments Time of assessment Followed infants for 2 years Intervention Outcomes

Participants, interventions and outcomes in reviewed studies

Author

A Bialocerkowski et al.

Bisinella and Birch24

60

All babies registered with the British Paediatric Surveillance Unit, March 1998March 1999 None

Eng et al.25

191

Infants under 15 months of age, diagnosed with OBPP referred to George Washington University and Medical Centre between 1981 and 1993 Showed classic signs of OBPP

Laurent et al.26

112

Infants who presented with a diagnosis before 2 months of age at the Texas Childrens Hospital between 1987 and 1990 Detailed explanation of how the diagnosis of OBPP was made Severity of brachial plexus lesion was based on clinical observation From 2/52, dynamic traction, active and passive movements of affected upper limb (n = 46) Not applicable Surgery: those who had absent deltoid/biceps at the end of the 4/12 (n = 28) Guided home physiotherapy exercise program (n = 77)

2, 4, 9, 12 months of age

Leblebicioglu et al.27

105

Infants diagnosed with OBPP as soon as possible after birth at the University Hospital Zurich, between May 1995 and December 1998

Monthly intervals up to 2 years of age or at discharge from treatment Strength of deltoid, biceps, wrist extensors, time to gain M3 of biceps From 2 months of age. No end point specied other than years

Lindell-Iwan et al.28

46

Infants diagnosed with OBPP, referred to Kuopio University Hospital, Finland, between 1975 and 1990. Divided into 3 severity groups: C5,6: mild; C57: intermediate severity; C5T1: severe Diagnostic criteria for OBPP provided Physiotherapy, occupational therapy, home program (n = 94) Surgical treatment (n = 59)

Noetzel et al.29

94

OBPP identied in newborn period (lack of antigravity upper limb function at 2/52) from St Louis Childrens Hospital between 1991 and 1997 None

Not applicable

British Medical Research Councils Movement Scale (improvement = 1 grade for at least one muscle) Conservative treatment (n = 53) Active joint movement, tactile sensibility, pickup test, grip strength, ability to grip, bimanual activity

1824 months of age

Strombeck et al.30

112

Children with OBPP evaluated at 5 years of age. Recruited from records at Kardinska Hospital, Stockholm between 1987 and 1998. Stratied by level of lesion: C5,6, C57 and C5T1 None

5 years of age

Xu et al.31

31

Children diagnosed with OBPP referred to Fujian Provincial Hospital, China, between January 1995 and June 1996

Surgery: no recovery of biceps by 3/12, surgery could consist of neurolysis (n = 9) or nerve transfer/grafting (n = 10)

Conservative treatment based on some recovery of biceps by 3/12. Treatment undertaken at local hospitals (n = 12)

Mallet Scale

Conservative management group: average of 3.6 years of age. No information for surgically managed group

ROM, range of movement.

Management of obstetric brachial plexus palsy

43

Appendix VI
Study design, quality and results
Author Bisinella and Birch24 Eng et al.25 Laurent et al.26 Study design Prospective case series Retrospective case series Retrospective comparative study Retrospective case series Retrospective case series Hierarchy of evidence IV IV III-2 Quality score 8 8 8 Main ndings 65% full and 20% useful recovery with conservative management. 15% had surgery (1 good, 2 fair and 2 poor results reported) Conservative management: 17% better, 35% same, 5% worse, 43% no follow-up Surgery: 90% improvement at 12/12 Conservative management: 100% attained near normal function at 12/12 (50% were reviewed) Surgery: no results summarised Conservative management: 100% attainment of function at 17/12 Conservative management: C5,6 most recovered <1/52, C57 recovered in >13/52 with some arm restrictions, C5T1 recovered >5/12 with poor arm function Conservative management: at 1824/52, 92% complete recovery, 11% mild weakness, 9% moderate weakness, 14% severe weakness C5,6 and C57: surgical group had signicantly greater range of shoulder movement compared with conservative management group (mean difference = 30% shoulder range of movement) After 3.5 years, 70% in the nerve transfer/grafting surgical group had good/excellent recovery compared with 0% in conservative and neurolysis groups, no different between conservative management and neurolysis groups (P > 0.05)

Leblebicioglu et al.27 Lindell-Iwan et al.28

IV IV

7 9

Noetzel et al.29

Prospective case series

IV

Strombeck et al.30

Cross-sectional comparative study Cross-sectional comparative study

III-2

11

Xu et al.31

III-2

Appendix VII
Study quality using the Critical Review Form Qualitative Studies21
Quality score Purpose clearly stated Literature review relevant Study design appropriate to study aims No biases present Sample described in detail Sample size justied Informed consent gained Outcome measures are valid Outcome measures are reliable Intervention described in detail (could be replicated) Results reported in terms of statistical signicance Analysis was appropriate Clinical importance of the results was reported Conclusions were appropriate Clinical implications of the results were reported Limitations of the study were acknowledged Total Bisinella and Birch24 0 0 1 0 1 1 0 0 0 0 0 1 1 1 1 1 8 Eng et al.25 1 1 1 0 1 1 0 0 0 0 0 0 1 0 1 1 8 Laurent et al.26 0 1 1 0 1 1 0 0 0 0 1 0 1 1 1 0 8 Leblebicioglu et al.27 1 1 1 0 1 1 0 0 0 0 0 0 1 0 1 0 7 Lindell-Iwan et al.28 1 1 1 0 1 1 0 0 0 0 0 0 1 1 1 1 9 Noetzel et al.29 1 1 1 0 1 1 0 0 0 0 0 0 1 1 1 1 9 Strombeck et al.30 1 1 1 0 1 1 0 0 0 0 1 1 1 1 1 1 11 Xu et al.31 1 0 1 0 1 0 0 0 0 0 1 1 1 1 1 0 8 Total 6 6 8 0 8 7 1 0 0 0 3 2 8 6 8 4

44

A Bialocerkowski et al.

Appendix VIII
Properties of OBPP outcome instruments
Outcome instrument Items Minimum score Joint-specic Mallet system (shoulder)10,32 Gilbert and Raimondi Scale (elbow)7 Ability to perform 5 upper lime functional movements ROM of elbow exion and extension, magnitude of xed exion deformities I (no movement) 0 No movement and severe xed exion deformity 0 Paralysis of hand, decreased sensation Scale Maximum score V (normal movement) 5 Normal elbow movement and no xed exion deformity V (normal/near normal active nger, thumb, wrist and forearm) active movement and hand sensation 5 (severe) Older children with OBPP who can follow instructions Developed for infants with OBPP Uses

Raimondi Scale (hand)7

Combined assessment of active movement of the ngers, thumb, wrist and forearm, hand sensation

Developed for infants with OBPP

Generic Impairment rating25 Combined assessment of scapula position, active movement of the shoulder and forearm, strength of biceps, hand function and hand sensation Strength of muscle groups in the upper limb 1 (complete recovery) Not stated

British Medical Research Councils Muscle Movement Scale14,32 Gilbert and Tassin Scale32

0 (no contraction)

5 (normal power)

Individuals with peripheral nerve injuries, requires the cooperation to following instructions Developed for infants with OBPP, as strength is assessed during play

Modied British Medical Councils Muscle Movement Scale

M0 (no contraction)

M3 (complete movement against gravity)

Shoulder abduction, shoulder external rotation, hand to mouth, hand to nape of the neck, hand behind back. No information was found regarding the Gilbert Scale for hand function.