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Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole, and today we're discussing the multidisciplinary brachial plexus peripheral nerve program at UAB Medicine. Joining me in this panel discussion are Dr. Erin Ransom. She's a Hand Surgeon, Orthopedic Surgeon, and an Assistant Professor at UAB Medicine. Dr. Drew Davis, he serves as the Medical Director for the Division of Pediatric Rehabilitation Medicine at Children's of Alabama. And he's also a Professor in the UAB Department of Pediatrics at Children's of Alabama. And Dr. Brandon Rock, he's a Pediatric Neurosurgeon and an Associate Professor at UAB Medicine. Doctors, thank you so much for joining us today. And Dr. Rock, I'd like to start with you. Tell us a little bit about the prevalence and complications of children with brachial plexus and peripheral nerve disorder.

Dr. Rock: So, the brachial plexus is a network of nerves that that connects the spinal cord in the neck with all the muscles of the arm. So the most common brachial plexus injury that we see is actually an obstetric injury or an injury that happens at the time of birth. That happens in about one out of every thousand or two out of a thousand live births in the United States. We see other brachial plexus and peripheral nerve injuries as well. It can happen with a car accident, motorcycle accident, you know, sharp injuries, such as glass or knives, things like that. And in our clinic at Children's our most common injuries, definitely the birth injury.

Host: Well then Dr. Ransom, can you expand on the cause that we know as of now and when you typically see these injuries?

Dr. Ransom: So, the majority of the patients that we see in our clinic are from brachial plexus, birth injuries. And so they occur during delivery and it's not just during spontaneous vaginal delivery, but it can also occur during C-sections as well. But at some point there is a stretch of the nerves as they go from the neck down into the arm, as Dr. Rock described. As far as the traumatic injuries that we see a lot of times those are also from the stretch and it can be from a motorcycle accident or a car accident, or from any way that the arm is stretched. And then the last least common way that we would see would be those penetrating injuries, where there's an actual stab or a laceration to the nerves themselves in that area.

Host: This is so interesting. And so Dr. Davis tell us a little bit about what's involved in the workup and how these are diagnose? And then I'd like you to get into some conservative management and nonsurgical treatment options for us.

Dr. Davis: So, whenever we see children in our clinic and most commonly, this is birth brachial plexus injuries, we're reviewing their birth history, getting that detailed birth history and any potential complications that occurred at the time, whether there was a history of shoulder dystocia, or a prolonged extraction, a C-section or a vaginal delivery. And then were, you know, asking questions about what the function of the extremity was, the arm was shortly after delivery, and then we're observing and examining for ourselves that day in clinic to either confirm what we think is a brachial plexus injury based on the history and the exam we see. Or perhaps considering another diagnosis such as hemiplegic cerebral palsy, which sometimes can occur in masquerade as a brachial plexus injury in a very young child. Typically we're seeing children within the first weeks and certainly the first few months of life. And so their neurologic exam can still be an evolution at that time if there are other confounding factors contributing to their presentation. And we're initially prior to considering any more aggressive intervention, just looking at the basics of a home exercise program and a occupational therapy program.

We want to make sure that families understand how to put an arm through the full range of motion at all joints and all joints that are effected, whether that's the shoulder, the elbow, the wrist, the hand, the fingers to make sure we don't lose range so that as the arm strength improves and the function improves, they've got a full functional range of motion. As children get a little bit older, certainly therapy continues to be a part of their intervention, but if they're not a surgical candidate then there are other things that we consider. Some children develop tightness because the muscles that are intact, you're overpowering the weaker muscles. And so at times we will perform botulinum toxin injections, which is somewhat more aggressive of an intervention, but not a surgical intervention. We at times will also have children go through more intensive forms of occupational therapy. One form in particular is called constraint induced movement therapy which incorporates aspects of retraining the brain where a child, because they didn't have as much functional use early in life may have developed a predisposition overall to use that extremity less. And so the principles of constraint therapy, which are taken from actually stroke rehabilitation, can be applied to the brachial plexus population.

Host: Isn't that so interesting now, Dr. Rock, tell us a little bit about the brachial plexus and peripheral nerve program at UAB and the collaboration with Children's of Alabama. Describe for us a little bit about the program highlights and features and tell us how the clinic has a focus that's engaging multidisciplinary teams to best treat these patients?

Dr. Rock: Our clinic is truly a multidisciplinary clinic, and that's something that we've watched develop in particular over the last five to 10 years. When I started in the program that it was already a, you know, a multidisciplinary clinic with neurosurgery and rehabilitation medicine, but we brought orthopedics into the clinic as well, and that has been a major contribution for our patients. As Dr. Davis mentioned that the treatments that are available for this, there are conservative treatments and of course, surgical treatment. Now most infants with a brachial plexus injury, 60 to 80% of them will recover function a lot of function on their own and will not go on to need a nerve reconstruction or nerve surgery. But while they are recovering, it's crucial that we pay attention to how the joints move in particular, the shoulder, even kids that recover pretty well. And certainly those that have nerve surgery and go on to recover after a surgery, they still require a lot of attention to the shoulder joint, and in the long-term that's, I think what really drives the outcome and how satisfied these kids and these parents are with their function. It's how well the shoulder moves. So having orthopedic surgery in the clinic, and ready to, you know, pay attention to that and intervene there with shoulder surgeries, as necessary as a real key part of what we provide.

Host: Dr. Ransom, why don't you jump in here and tell us a little bit more about where orthopedics fits in to this picture and to create this clinic in multidisciplinary approach?

Dr. Ransom: Like Dr. Rock and Dr. Davis mentioned the shoulder and problems that they can have with the shoulder coming from the weakness, and the nerves can be a tricky problem to tackle. The shoulders are a really complex joint, and that it, it's almost like a golf ball on a golf tee instead of a ball in a socket. And a lot of the movement of the shoulder what's important about it is the force couple between the muscles that internally and externally rotate the arm and the muscles that lift and depress the shoulder too. And with part of those being injured you lose that mechanism of how it moves. And so all of the stretching and the Botox and the intervention that we have for these kids while they're recovering are really helpful to help make sure that that shoulder moves normally, even though the baby doesn't have the way to move the shoulder itself. And that's where the parents participating in stretching every single day really comes in to being important for these kids.

Host: Well, it certainly, doesn't Dr. Davis, what are some of the special things that your team does to go above and beyond? Tell us a little bit more about the program, how you interact with the parents and what you would like referring providers to know about this program at UAB Medicine?

Dr. Davis: Certainly. Well, and one of the things to add on to what's been stated about the multidisciplinary nature of this. One of the things that we all benefit from is we have an occupational therapist that has been working in this clinic longer than any of us. And so there's a degree of institutional wisdom in this clinic in continuity over time, that has really been remarkable. It's rare that you have a therapist that's been working in the same area for, you know, over a decade. And so one of the things that's very unique is in addition to coming into our clinic and seeing, you know, all these highly trained physicians is you have an occupational therapist who spends time in a hands on fashion with these children and these families, teaching them everything that they need to know at this particular, whatever stage of care they are in. If it's their first visit, their fifth visit or their 10th visit, or if they're coming back years later, just for surveillance of their outcome and a maintenance program, they're in the hands of a very experienced occupational therapist.

Not only are they in the hands of that experienced therapist, but this person has a network of folks around the state that they know that they can reach out to, to help provide localized care so that people aren't coming back to UAB and children's more frequently than they have to. I think additionally, the fact that when children come to clinic, of course, we each have our areas of focus, but we are continually looking at the child's overall development. Certainly an arm is an important part of their development, but we have to take into account the whole child. And so if there are other challenges with development, a child may not respond to more engaged therapy versus a child who has no other medical or developmental issues and is very engaged and therefore might benefit from the constraint therapy I mentioned earlier. That can be applied at a very early age with the child that is very engaged. So we're always looking at the entire child's development. What can we do specifically for the arm that we're looking at, or the joint in particular that we may be most focused on, but also how does that fit into the context of the child's overall development, as well as the family structure, where they live, the resources they have, etcetera.

Host: And Dr. Ransom, your final thoughts and what you would like other referring providers to know about the program at UAB and Children's of Alabama?

Dr. Ransom: I think just knowing that not only is the family and the child going to get to see three different specialties, plus an occupational therapist with years of experience we all work together as a team and really collaborate on deciding what the, what the best treatment is for these children. And we work together so though they may have the same four individual people. They're actually seeing a team that's working together for the best plan for their child. And I think that that's something special and different that we offer here. And that is a great program.

Host: And Dr. Rock last word to you, what can be done between referral and the actual appointment with the specialists and the team, and what would you like to summarize? What would you like other providers to take away from this great segment about this collaboration between UAB and Children's of Alabama for the brachial plexus and peripheral nerve?

Dr. Rock: The key points to take away from this one for infants, with a brachial plexus injury, we want to see them as early as possible. As I said, 80% of these kids may get better on their own without, without a surgical intervention, but having them in the clinic early, it just a couple of weeks of age, and then being able to follow them over those first six to eight months of life, we really get a sense of how they're progressing and it makes it a lot easier to make decisions about whether they need a nerve operation or not. And the second point I'd like to make in closing is that we've talked a lot about infants with birth injuries here, but this is a true nerve clinic. And we see patients of all ages up to their early twenties at Children's of Alabama with nerve injuries of all different causes. And with our team, we have the ability to do, you know, primary nerve repair with grafting, nerve transfers, tendon transfers, whatever, whatever operation is appropriate for a given person to increase in and restore their function to the greatest extent possible our team is ready to provide that. So I appreciate the opportunity to chat with you guys about that today.

Host: Thanks to all of you, what a great informative segment. Thank you again for joining us. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.