PINNING THE SLEEVE
Don't pin the baby's arm sleeve to the shirt. They have learned over the years that this can cause some real problems with the shoulder as no one knows whether a newborn is going to fully recover or not.
RANGE OF MOTION
I remember therapists discussing PROM and AROM with me. They assumed that I knew what they were talking about when I didn't - so here it is:
- PROM = passive range of motion - you move your baby's arm
- AROM = active range of motion - your baby moves their own arm
ROM = range of motion exercises - a series of movements that you will do with your baby's arm to give it attention and keep it supple and to remind the brain that your baby has an arm. Make sure that you show your baby their hand/arm - they need to actually see it - "yes, we're disconnected right now (no nerves attached) but there is an arm that you have to remember".
- Please learn how to do range of motion exercises from an OT or PT.
- Do them slowly and softly.
- PROM should not cause pain.
- Doing it harder and faster may injure your baby's arm and traumatize your baby.
- PROM does not make the nerves grow any faster.
- PROM does not stop contractures from occurring.
- Do it with each diaper change. Find a way to make it fun. Choreograph it to music. Use warm compresses. Do a little massage with some lovely lotion.
- See it as a very loving, bonding moment.
CONTRACTURES
You will probably hear the word "contracture" throughout your child's life. A contracture occurs when there is a muscle imbalance. Why is there a muscle imbalance in the first place? Because one muscle has a great connection to the nerve - it's getting full strength - while the other side, may just be getting a trickle - or nothing.
It takes two muscles to make a movement. One contracts and the opposite side gives resistance. If there is no resistance - nothing stopping it - then the stronger side, the side that is contracting, won't stop contracting. In time it will get tighter and shorter. At some point it may not be able to be stretched at all.
The only thing that can be done to stop a contracture is to strengthen the weaker side to get rid of the muscle imbalance. But since this muscle imbalance happened in the first place due to nerve injury, sometimes the only way to achieve more balance is through surgery -- release the tightness and moving in a section of strong muscle to help the weak muscle do its job.
Another way to achieve more balance is to strengthen the weak side with pointed electrical stimulation but that weak side has to be connected to a working nerve.
Some contractures can be caused by other contractures --- for example the elbow contracture may be caused by shortening of the biceps because of contracture in the shoulder.
COMPENSATION
Next is a foundational concept - thanks to Dr. Karen Pape (may she rest in peace) and Billi Cusik, PT (creator of Theratogs) who taught these concepts in their classes and workshops.
In those early recovery years, don't allow compensation. Exercise only what works.
What does "compensation" mean? It's when you want to make a movement with a specific muscle and the body wants to make that movement, but since it can't make that movement or parts of that movement, it gets other muscles (that shouldn't be involved) to help make that movement.
You may see a child try to raise their arm overhead and it looks good, looks good and then all of a sudden you see the child bending their back to help raise the arm higher -- by bending the back, it's showing you that the child is calling on other muscles to become helpers. The arm muscles are no longer doing the work, the torso and back muscles have taken over.
To see it more clearly, ask the child to raise up their non-affected arm. Then ask the child to raise up their affected arm. The child will never back bend with the non-affected arm.
Compensatory movements can become necessary when you are past your growing years and you are already at the end of your nerve recovery. We just don't want any helpers when the child is young and still trying to grow nerves and teaching their muscles how to work all on their own.
In other words, no cheating please. Have the "correct" muscles do the movement to the end that they can and when they can no longer, then stop. Start the movement from the beginning again, stop again right at the point where compensation would begin. Strengthen only what works.
Here's something else to think about: "Habit hides recovery". In time and with work, your child might just be able to make that complete movement. But since they've learned how to cheat, and to cheat well, they will continue cheating even if they don't have to.
Learn more about this in our upcoming Webinars with Cindy Servello OTR. (see "Webinars" in the menu above)
WEIGHT BEARING - WITH SUPPORT PLEASE
Weight bearing is important to the development of the function of the arm. However, it is important to SUPPORT the shoulder or the elbow so that the joints remain in the right position.
At a workshop, Dr. Pape taught us that children's shoulders are not specifically created to carry the weight of their body. (We are mammals who walk upright.) So why would you put the weight of a body on a shoulder that's not formed correctly (flat glenoid fossa) and that doesn't have the muscular support of a normal shoulder (and may even have a posterior dislocation as many of the children do)?
MANY REASONS FOR REDUCTION IN FUNCTION NOT NORMALLY DISCUSSED
Growth spurts cause a reduction in function. Muscles grow faster than nerves. If you see your child's arm lose some function, ask yourself "are they in a growth spurt"? Are they eating more now? Are they shooting up in height? Don't see your specialist during a growth spurt - see them once the spurt is over and the arm is moving at it's previous functional levels.
Reduction in function and/or pain in the arm that comes on without a reason could be a barometer to a child becoming sick (fever, cold, flu, virus, etc.). If all of a sudden, the child complains of an achy dull pain in the arm, take that moment to given them an immune system boost with fresh fruit or some supplements and watch for upcoming illness.
DIAPHRAGM INVOLVEMENT
Lack of oxygen causes a reduction in function. Keep a portable little pulse-ox clip around. Children who have brachial plexus injuries may also have undetected diaphragm issues and their oxygenation levels may be lower than they should be at times. If it's low, they may not have enough oxygenation to move the arm as best as they usually can at that time. Get an assessment from a pediatric pulmonologist if you see times when pulse-ox readings decrease.
If you see a pulmonologist for your child, make them aware that children with BPI are prone to osteopenia in the affected arm (pre-cursor to osteoporosis). This knowledge will help them choose more appropriate medication.
BTW, what is the best exercise to strengthen a diaphragm? Singing!! Luckily and thankfully, there are so many opportunities for kids to sing: school choirs, religious community services and religious choirs and more. There are also numerous tools that one can use for breathing exercises - ask the pulmonologist about what they think may be best for your child.
BURN & INFECTION RISK
Arms that are affected by nerve injury are very different from arms not affected.
For one, they are at high risk for burns. Sunburn, kitchen burn, any kind of burn. I don't know exactly why (yet) but an arm affected by BPI can get sunburned in a snap of the fingers, while the other unaffected side might hardly get anything. So get the best and least toxic sunscreen for not only the arm, but the entire side, including the face. (ewg.org) And if going to the beach, wear protective clothing as well. So many options now with those sun shirts and hats.
Kitchen burns are possible especially with someone who has reduced or no sensation in their affected arm/hand.
The arm may be at greater risk for infection because there may be decreased circulation. If there is any infection, please go see your doctor asap. If the infection is bad, discuss using microcurrent electrical stimulation (very inexpensive) or a compression sleeve to increase the circulation.
Never use the affected arm for blood pressure readings, for blood work or for any type of shot. It can be painful and there is that infection risk.
SPECIAL POSITIONING OF THE ARM
The affected arm will need specific positioning for any medical procedure or test. If special positioning is not applied correctly, the arm can be injured or re-injured more severely. Individuals who don't have a BPI, can get severe traumatic BPI with wrong positioning. Prone position (face down) is high risk for creating BPIs - this is the position they put you in when you have Covid and are on a ventilator.
If your child is old enough to speak up for themselves, ask the medical professional to include your child in the positioning and have them verbalize if a position causes pain or not.
Special positioning is important for ALL medical procedures including xrays, scans and mammograms.
OT's AND LIFETIME PROBLEM SOLVING
Work with an OT to problem solve issues that are difficult for your child at different stages of development. This can make a world of difference especially during puberty - learning how to don a bra, work with hair, etc.
Our OT helped us figure out how to do specific college projects (3D art) one-armed. It was amazing!
ALTERNATIVE OPTIONS
Yes, working with a chiropractor, acupunturist, naturopath, homeopath, digeridoo healer, crystal healer, Reiki practitioner, massage therapist and all other kinds of alternative options MAY be really good. But like everything else in life, there are good practitioners and bad practitioners. My suggestion to you is that you go to that practitioner to get your own treatment. Go for more than one treatment. Your gut will let you know if you think that this practitioner is the right one for your child. Basically what I'm saying is "don't experiment on your chlid". They are already in a state of trauma to some degree - you don't want to add to that. Check it out yourself and you will know for certain by your own experience if you feel this is the correct option for your child.
Understand that if any alternative treatment could cure a bpi, the world would know about it and everyone in the BPI world would be doing it and that's just not the case. Alternatives can give ease, can smooth things out, can help someone sleep better - but fix ruptured or avulsed nerves? Sorry - just not happening yet. Maybe sometime in the future with alien technology? One can always hope.
SPEAKING OF PUBERTY
Puberty is a MASSIVE game changer. The child's body grows fast, hormones rage and arm function can be sent backwards fast.
Time will tell if the changes are temporary or permanent. For this reason, if surgery is suggested just before puberty, you may want to consider waiting a bit. Talk to your specialist about this in detail.
INTRODUCING MAGNESIUM
Studies show that most people (injured or not) are deficient in Magnesium. If there are spasms or cramps or muscle pain, a bath with Epsom Salt in it (magnesium sulfate) may be helpful. A daily oral dose of Magnesium (see Magnesium Calm OTC in any drugstore) may be helpful. Although there is a lot published about this, see our Adult OBPI page for a link to a published study about magnesium and pain.
DRIVERS EDUCATION & "VOCATIONAL REHAB" (A COUNTY OFFICE)
We found a local rehabilitation hospital that had driving re-education for stroke victims. We met with an OT at the organization who did a full assessment with an in-office driving test module (half a car). The OT decided what modifications needed to be made, and made them to the drivers-ed vehicle used for driver's ed. Ten OT drivers-ed lessons to learn how to drive and how to drive with the modifications. At the end was given a "prescription" for the auto modification organization to make the needed modifications. The personal car was modified and used for the formal driver's ed test.
VOCATIONAL REHABILITATION (a county service) would have paid for all the modifications if the car was needed to get to a job. Vocational Rehabilitation may also cover some portion of tuition or college expenses and retraining at a later time if needed in order to work. This is different by state and county so I can only state what I know about my state and county.
