Evaluating the feasibility of implementing the Sup-ER protocol for infants with brachial plexus birth injury
Emily S Ho1, Karen Klar2, Howard M Clarke3
1Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
The Sup-ER protocol helps infants with brachial plexus birth injury. Modifying eligibility criteria improves identifying infants who benefit from this shoulder repositioning program.
Area of Science:
- Pediatric Orthopedics
- Neonatal Care
- Rehabilitation Medicine
Background:
- The Sup-ER protocol uses external rotation (ER) to treat progressive loss of passive range of motion (PROM) in infants with brachial plexus birth injury.
- British Columbia Children's Hospital (BCCH) uses specific criteria for infants aged 4-8 weeks with decreased shoulder ER PROM and/or Active Movement Scale (AMS) scores ≤2.
Purpose of the Study:
- To evaluate the effectiveness of the BCCH eligibility criteria for identifying infants suitable for the Sup-ER protocol.
- To assess the precision of current criteria in selecting appropriate candidates for the intervention.
Main Methods:
- A retrospective cohort study analyzed infants aged 4-8 weeks based on PROM and AMS scores.
- Sensitivity and specificity analyses were performed to evaluate the BCCH criteria's ability to identify infants with incomplete shoulder function versus those with functional outcomes.
Main Results:
- 53% of infants met the BCCH Sup-ER protocol criteria at a mean age of 5.8 weeks.
- The BCCH criteria demonstrated 100% sensitivity and 71% specificity for identifying infants with incomplete shoulder function.
- Removing the AMS supination score criterion improved specificity to 84% while maintaining high sensitivity (97%).
Conclusions:
- Modifying the BCCH criteria to include all infants aged 4-8 weeks with AMS shoulder ER ≤2 and/or decreased shoulder ER PROM enhances the identification of infants who would benefit from the Sup-ER protocol.
- Adjusting the criteria can improve the precision of patient selection for this important intervention.
Background:
The Sup-ER protocol involves a repositioning program for infants with brachial plexus birth injury to position the shoulder in external rotation (ER) to address progressive loss in passive range of motion (PROM). The British Columbia Children's Hospital (BCCH) eligibility criteria for this protocol are infants aged 4-8 weeks with decreased shoulder ER PROM and/or Active Movement Scale (AMS) shoulder ER and/or supination scores ≤2. The resources needed to implement this protocol in large clinics have not been studied.
Purpose:
This study aims to evaluate the BCCH criteria that are used to identify appropriate candidates for the Sup-ER protocol.
Study Design:
A retrospective cohort study was conducted to identify the percentage of infants who would have been recommended the Sup-ER protocol based on their PROM and AMS scores between 4 and 8 weeks of age.
Methods:
A sensitivity and specificity evaluation was used to describe the BCCH criteria's ability to identify infants in this historical cohort who went on to have incomplete shoulder function (ie, true positive) vs infants who had functional shoulder outcome at 9 months of age (ie, false positive).
Results:
At a mean of 5.8 weeks (95% confidence interval [CI] 5.3, 6.3), 46 of the 87 (53%) infants satisfied the BCCH Sup-ER protocol criteria. Forty-four (51%) were female, half (n = 45) were left side affected, and 88% had upper plexus injury. The BCCH Sup-ER protocol criteria had sensitivity of 100% and specificity of 71% to identify infants with incomplete shoulder function. Removing the AMS supination ≤2 score criterion from the criteria improves the specificity to 84%, while sensitivity remains high (97%).
Conclusions:
Modifying the BCCH criteria to all infants aged 4-8 weeks with AMS shoulder ER ≤2 and/or decreased shoulder ER PROM improves the precision of identifying infants who would benefit from the Sup-ER protocol.
