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The "Pyramid Approach" to Therapy in Brachial Plexus Birth Injury: Multicenter Comparison of Nerve Transfer Outcomes
Alejandro J. Friedman, MA
1, Victoria Robbins, BS
1, Megan Gotlieb-Horowitz, MS, OTR/L
1, Mandana Behbahani, MD
1, Erin Meisel, MD
2; Steven M. Koehler, M.D.
1(1)Montefiore Medical Center, Bronx, NY, (2)Children's Hospital of Los Angeles, Los Angeles, CA
Introduction: After nerve transfers for brachial plexus birth injuries (BPBI), therapy is necessary to activate nerve transfers and optimize functional outcomes. However, children may not attend therapy for many reasons, with socioeconomic barriers to care being a major cause. Adopting the concept of a "Pyramid Approach" (Figure 1), we aim to analyze whether a streamlined process for patients to attend therapy (at a trusted location, close to patients' residence, where the surgeon and therapists communicate on patient goals, progress, and plan of care) leads to improved functional outcomes following nerve transfers for the treatment of BPBI.
Materials and Methods: Patients undergoing spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfers from two institutions with the same surgical approach/technique were included. Institution A utilizes the "Pyramid Approach" to therapy: the surgeon works closely with senior therapists, experienced in the treatment of this population, to hand select a therapy office and treating therapist based on patient location. Institution B allows patients to select a therapy office and patients must set up their own appointments. Institution B does not have direct communication with the treating therapists. Active Movement Scale (AMS) scores preoperatively and postoperatively were collected and compared as outcome measures. Wilcoxon signed rank tests and Mann-Whitney U tests were used to compare outcomes. P-values <0.05 were considered statistically significant.
Results: A total of 28 patients from two institutions were included and underwent surgery between March 2022 - June 2024. Gender, average age at surgery, and average follow-up time was not significantly different between groups. AMS scores for shoulder abduction (SA), shoulder flexion (SF), and external rotation (ER) did not differ at baseline (p=1.0, p=0.365, p=0.053). Patients from Institution A and Institution B both had significant improvements in AMS scores (Table 1). However, when comparing final AMS scores, the groups were significantly different in SA (p<0.001), SF (p<0.001), and ER (p<0.001). When specifically focusing on the ability to improve ER AMS scores, Institution A had significantly higher scores for meaningful recovery (Table 3).
Conclusions: Utilizing the "Pyramid Approach" to streamline the rehabilitation process contributes to significantly higher AMS scores and outcomes for BPBI children undergoing nerve transfers.
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