St. Louis Children’s Hospital

Medical Treatment				Initial Management
				Assessment
				Physical Therapy

Medical treatment of brachial plexus palsy includes diagnosis, ongoing assessment, and appropriate therapy.

Medical treatment of brachial plexus palsy begins with the following steps:

• diagnosis by neurologic examination
• identification of associated injuries
• education of the family about the disease and therapy
• daily range of motion exercises
• monthly assessment of motor strength
• for infants with persistent weakness, referral to Brachial Plexus Center before 2 months of age

The infant's muscle strength and arm and hand movements are measured every month during the first 6 months. We use three grading systems to document muscle strength and functions of the upper extremities.

Motor Strength Assessment Scale
The Modified British Council Scale for muscle strength, illustrated below, is used for semiquantitative assessment of an infant's muscle strength.

1 - No or trace muscle contraction
2 - Muscle contraction without gravity
3 - Muscle contraction against gravity
4 - Muscle contraction against resistance
NG - Not graded due to difficulties

This muscle strength grading system is applied to each muscle group of the affected upper extremity, as shown below:

Muscle	Strength
Deltoid
Shoulder external rotators
Shoulder internal rotators
Biceps
Triceps
Wrist flexors
Wrist extensors
Finger flexors
Finger extensors

Joint Movement Grading

This grading system allows for quantitative documentation of the joint movement.

Observation	Central Grade	Numerical Score
No joint movement	0	0
Flicker of movement	0+	0.3
Less than half range	1-	0.6
Half range of movement	1	1.0
More than half range	1+	1.3
Good but not full range	2-	1.6
Full range of movement	2+	2.0

(Note: The best movement observed during evaluation is graded.)

This joint movement grading system is then applied to specific movements of each joint of the affected upper extremity, and a total numerical score is found.

Joint Movement	Central Grade	Numerical Score
Shoulder adduction
Shoulder abduction
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
Finger flexion
Finger extension
Total Numerical Score

By recording these objective data for muscle strength and joint movement, a patient's progress can be followed through a series of examinations.

Mallet Scale

Another grading system to document functional changes of the shoulder and arm is the Mallet Scale, which is very useful in children older than two years. (Because it requires the cooperation of the patient, it is not suitable for younger children.) Click on the image to see a larger version.

Mallet Scale Click for larger image

Physical therapy is the only treatment necessary under these conditions:

• The infant can bend the elbow against gravity and move the wrist and fingers by 3 months of age.
• Muscle strength continues to improve.