Initial Assessment for Physical Therapy

Upon initial evaluation of each patient it is important to begin the process noting previous studies, assessments made by Brachial Plexus physicians and any additional co-morbidities such as Torticollis, Diaphragmatic paralysis, Horner's Syndrome, or clavicular fractures that may affect the treatment of these patients.

The physical evaluation then proceeds with the assessment of each patients function, active and passive range of motion. Different motor grading systems are available, however in our center the British Medical Research Council Muscle Grading system is utilized for the perinatal period in addition to the Mallet Classification in older children >2 years old.

Joint integrity in the glenohumeral, elbow, and wrist joints is evaluated and the presence of any malalignment is then noted. Clavicular and humeral fractures are ruled out. However, if present treatment in the form of joint protection and positioning are utilized. These fractures heal rapidly if recognized early.

Assessment of muscle tone is also made, observing for atrophy and normal development. A determination is made if the affected extremity is flaccid or hypotonic. A natural progression of tone will begin proximal to distal as nerve regeneration occurs. Age appropriate reflexes such as Moro, 3 months, and palmar grasp, 6 months, are utilized to assess the degree of injury and follow recovery. These reflexes will be absent in the affected arm and will be present with eventual recovery.

Sensations to sharp and dull pain, deep pressure, light touch, vibratory and proprioception are used to evaluate the level of injury. Sensation to pain may be difficult in the newborn period. However, facial grimaces, crying or protective reactions may help in our assessments or input from parents is always valuable. Noting the degree of awareness each child has for the affected extremity is also valuable as we have seen that patients with no awareness of the affected arm tend to have more severe injuries and slower recovery.

A final area of assessment is whether each patient is meeting developmental milestones through their growth. Gross motor and fine motor coordination are followed for age appropriate development. Social interactions with family, friends, teachers, in addition to relationships are assessed for proper development. Language and cognitive skills are also followed to ensure that each patient is at their age appropriate level.

Next: Classification

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