Towards a Motor Ability Training Table for

Rehabilitating
Children with Obstetric Brachial Plexus Lesion

Alberti, Eduardo J.1, Pichorim, Srgio F.1, and Brawerman, Alessandro2

1School of Electrical Engineering and Industrial Computer Science, Federal
University of Technology of Paran
2Computer Engineering Department, University of Positivo
Curitiba, Paran, Brasil
AbstractObstetric Brachial Plexus Lesion (OBPL) is an
injury of the cervical spine and chest characterized by
blockage of one or more brachial plexus nerves, usually
during the child delivery procedure. Research indicates that
the number of infant OBPL cases has being growing in a
much faster rate than the population growth. Despite that,
most of the equipment and electronic devices employed to
help and accelerate the OBPL treatment are designed for
adult use, treating kids as a miniaturized adult. This work
proposes a simple yet efficient motor ability training table,
specifically designed for infant use. The training table uses
games, with light, sound and several complexity levels to
arouse the child interesting and to make the treatment more
challenging. On the top of that, a computer system that
presents patient progress through graphical reports helps the
professional to further analyzed the treatment result.
Keywords: OBPL, rehabilitation engineering, motor ability training
table

1. Introduction
The OBPL - Obstetric Brachial Plexus Lesion - is caused
by excessive traction of the neck, head and arm during the
delivery procedure, exceeding the tolerance thresholds of the
nerves [1], [2].
The rate of OBPL cases has been growing along with population
growth, but in a much more considerable proportion,
about 76 %, in Brazil. According to [3], children rehabilitation
technology did not follow this growth, the technologies
developed are still based on adults characteristics.
This project proposes the development of a motor ability
training table to aid in the treatment of OBPL having as its
main focus children rehabilitation. In the following sections,
topics concerning the formation of OBPL lesion, treatment
techniques, types of injury, the project development and its
specifications are discussed.

2. Obstetrical Brachial Lesion

This section presents fundamental concepts such as the

formation of Obstetric Brachial Plexus Lesion, its causes,
residual deformities, and current treatment possibilities.

2.1 Lesion Formation

The Obstetric Brachial Lesion or Obstetric Brachial
Plexus Lesion is an injury of the cervical spine and chest
characterized by blockage of one or more nerves of the
brachial plexus [4]. The lesion is usually the result of direct
trauma caused during delivery. [2].

Research conducted in 2000 and 2010 shows that the

rate of tocotraumatism cases (one should take into account
the aggregation of all cases of various types of traumas)
occurring during delivery, increased approximately 75.6 %,
and mortality involving this type of injury accounts only
to 0.6 cases per 100,000 births [5], [6]. It should be taken
into account, when interpreting such data that, according to
the Demographic Census of 2000 and 2010, the Brazilian
population grew by 12.3 % during this period [7].
Research indicates that the number of cases is incremented
as the infant approaches the range between 4 and 5 kg, which
can be seen from the graph of Figure 1.
Fig. 1: Relationship between number of cases of OBPL and
weight (in grams) of the fetus at birth. Based on [8].
A study conducted by [9] relates, in 311 cases, the number
of individuals affected by OBPL versus the type of delivery.
This is depicted by Table 1. Note that the sum of births by
forceps and suction exceeds the number of assisted births,
this is due to the fact that births with the aid of forceps
were performed after failure of Ventouse use and Caesarean
section.
Table 1: Types of birth versus number of cases. Adapted
from [9].
Type of Birth Studed Group England 1994-1995
N. % %
Spontaneous vertex delivery 183 59 73
Assisted delivery 113 36 * 10,6
Ventouse 87 28 5
Forceps 45 14,5 7
Breech 10 3 1
Caesarean section 5 1,5 15,5

2.2 Types of Lesion

The OBPL is classified taking into account the gravity and

the components involved in the lesion. Thus, the lesion can
be split into three types: Erb-Duchenne Palsy, Total Brachial
Plexus Lesion and Klumpkes Palsy [4].
_ Erb-Duchene Palsy: in this modality, the injury occurs
between the C5 and C7 vertebrae. The arm is in
a position called "waiters tip", with extension and
pronation at the elbow and wrist and fingers flexed,
as shown in Figure 2. In this case exists decrement of
sensitivity, but the movement of grip is intact [6]. Note,
when comparing photo A and B, how the arm position
and the fingers flexion are characteristics of this type
of injury.
Fig. 2: Typical appearance of the newborn with ErbDuchenne brachial plexus lesion. Adapted from [10], [11].
_ Total Brachial Plexus Lesion: in this case, all vertebrae
from the C5 to T1 have their roots affected. The
sensibility and all reflections are absent, the children
does not move or lift the arm[6], [11], this can be
observed by the Figure 3, note how the left arm of
the patient is shown still.
_ Klumpkess Palsy: in this modality the vertebrae C7,
C8 and T1 are envolved, paralyzing the hand muscles,
arm flexors and wrist and fingers flexors [13]. The
Klumpkes Palsy is the most rare of all types of

brachial plexus lesions and response to less than 1 %

of the cases [5]. This type of paralysis may affect the
Fig. 3: Total Brachial Plexus Lesion, Clinical Case. Based
in [12].
cervical sympathetic fibers, taking ipsilaterally Horners
syndrome, present on the same side of the affected limb
[2], [14].

2.3 Residual Deformities

The limitations showed by the subjects affected by the
OBPL may vary according with the type of the lesion.
According to [15], the patient may present inability to
understand and execute tasks requiring bilateral motor skills
such as catching a ball or a large object. The residual
deformities, according to [16], may be classified in 4 distinct
types, taking into account the physiological/anatomical point
of this deformity, being:
_ Shoulder: the subjects affected by OBPL usually
present difficulties in the movements of adduction and
abduction of the arm, the main motor function of the
shoulder [11]. Individuals may also present limitations
of active abduction and lateral rotation, which can be
seen from Figure 4. Note how the right upper limb
movements are limited when compared to the left upper
limb [11].
_ Elbow: the residual deformity at elbow is often developed
as a flexion of 45-90 degrees, which may
be aesthetically disturbing. There is also a muscle
imbalance summed with forced flexion of the elbow,
resulting in abnormal bone growth caused by the use of
very rigid immobilizing or splints during the recovery
process [11].
_ Forearm and Hand: residual deformities in the forearm
and hand are determined by lot distribution, extension
and type of the OBPL. While hand paralysis due to
Klumpke lesion may be continuous, in the forearm, is
common the appearance of deformities of pronation, as
shown in Figure 5. Note the contraction of the forearm
and elbow flexion [11].
Fig. 4: Residual deformities in the right shoulder of a 6 years
old child with obstetric brachial plexus palsy.
Fig. 5: Residual deformities of the forearm and hand in a
child affected by OBPL.

2.4 Treatment
The Orthopedic Management or physical therapy, is the
most appropriate treatment for the ones affected by OBPL
and has as objective the early treatment in the newborn and
child, in order to avoid deformities during the period of
spontaneous recovery [15].
According to [11], the passive movements made during
the exercise promotes the extension and flexion of the
complete arc of all articulations.
Below are shown some of the exercises used during OBPL
treatment. According to [15], each of the exercises should
be performed repeatedly, several times per day.
2.4.1 Sensorial Development Exercises

The sensorial stimulus, in order to increase awareness that

breastfeeding has on its own member, can be performed
using a soft towel, gently massaging the arm, or using his/her
own arm, massaging his/her own body [17].
Be aware of the affected limb is essential for the good
progress of treatment as a patient who has no sensibility to
the member can neglect it and continue to perform tasks
only with the "normal" member.
2.4.2 Motor Ability Training Exercises
It is necessary to train grip and manipulate objects with
both hands and also just the affected limb. To this end,
the therapist can use objects of any kind. To encourage the
active use of the atrophied member exercises that are used
in everyday situations, such as tying shoes, draw and pick
up objects may be strategies for the refinement of activities
and for developing more accurate coordination for specific
activities [17].
Exercises to gain motion amplitude or motion range
are also important since by gaining motion amplitude one
reduces the risk of contractures, mental and physical stress
and improves blood circulation [18].

3. The Motor Ability Training Table:

Specification
The training table proposed is a therapeutic device for
the purpose of bringing the physiotherapist and the bearer
of OBPL an alternative tool for qualitative and quantitative
analysis of brachial plexus injury treatment.
According to [18], the therapist has tools for application
of the exercises, but none of these are devoted exclusively
or focuses on the OBPL treatment. The tools used by
professionals are usually improvised materials such as toys,
weights, pulleys and balls.
The development of rehabilitation technologies is occurring
at a fast pace and the devices are becoming more
individualized, when taken into consideration the type of
disability or inability to move. In [3], published in 1996, the
authors were concerned with enabling technologies exclusively
for children. Current technologies are aimed at adults,
eventually considering children as miniaturized adults. This
is not enough, since the motor and cognitive functions of a
child are in constant change during his/her growth.
The training table constructed consists of a module made
of wood and glass, and divided into eight segments, as shown
by the diagram of Figure 6. Each of the eight segments has
an infrared touch sensor and LEDs in two colors, green and
red, and play a note of a eight-note musical scale, from C
to C.
These features together form a tool for dynamic exercises.
The patient exercises by triggering the segments
through touch, as soon as the training table asks for it. The
physiotherapist has the ability to choose what will be the
exercise performed. An example is to perform a sequence
of ordered movements, i.e., the patient should operate with
the OBPL affected member by all segments, one at a time,

progressively. The table will temporarily turn on the leds of

Red color in one segment to tell which should be activated,
emits a musical note (for the segment) and wait for the
Fig. 6: Diagram of the training table.
patient. If the patient triggers the correct thread it turns
green again, otherwise the thread will flash symbolizing the
error. Figure 7 shows step-by-step the training table basic
operations.
Fig. 7: Basic operation of the training table.
During the exercise, the training table system sends data,
related to the exercise, to the computer to which it is
connected. The table is able to count time and errors during
the exercise execution. Whenever the table system asks the
patient to trigger a segment, the time between the actuation
by the table itself and by the patient is accounted, this is
called arrival time. Whenever a segment is triggered by the
patient, the table accounts the duration of this actuation,
this is called actuation time. Such measures are important
to further analyze the progress of the patient response time
according to the complexity of the exercise.
The system allows the physiotherapist to select the complexity
of the exercise and stores the progress of each
patient in each exercise performed. The exercise complexity
is related to how fast each of the segments is trigger by
the system, the shorter the time of drive, more attention and
flexibility are required by the patient. There are 10 levels of
complexity, which can be used in all exercises, ranging from
one second apart (easy level) to 1/10th of a second (hardest
level).
To monitor the exercise, a computer system was developed.
The system controls/monitors the exercises, receives
data regarding the patient movement and presents a graphical
analysis of such information. The system is capable of
registering patients and storing personal data progress of
each registered patient, as shown in Figure 8. The physical
therapist can also monitor and control the execution of the
exercises through the computer system, as shown in Figure
9.
Fig. 8: Registration Screen of the Controling System.
Fig. 9: Exercises Execution Screen.
The system allows a temporal analysis of the exercise,
through the construction of graphs with the data collected
during the execution of the exercise. Figure 10 shows the
history exercise screen. It is important highlight that the
system, by itself, does not have any intelligence to perform
data analysis at this moment. It only generates graphics to
be analyzed by the responsible professional.
Fig. 10: Exercise history.

3.1 Related Work

The search for related work did not pointed out many
items. As mentioned before, there is a bad habit of considering
children as miniaturized adults, thus there is not
many training devices for kids. This section presents the
more relevant related work found.
The authors in [19] describe the development of a generic

programmable platform to aid in patient care with physical

disabilities, based on a set of non-invasive sensors that
can track movements, touches and eye poking. The sensor
signals are conditioned and processed in a computer system.
[20] describes the development of a multimedia workstation
for children rehabilitation. Based on a cognitive/sensory
system, one of the first ever developed, that works on
neuromuscular functions. The proposed system uses EMG
signals captured to study muscular information.
Finally, although there is not an equipment or device
developed, it is important to mention that the authors in[21],
[22] discuss about exercise techniques that can be applied
during a motor dysfunction treatment.

3.2 Discussion and Results

Is it possible to train a carrier of obstetric paralysis
through physical therapy methods? The literature states
that it is. According to [15], [11], [23], the orthopedic
management is highly recommended as an instrument of
neuromuscular recovery and surgical treatment is indicated
only in cases of delayed recovery or when there is no
response to physiotherapy treatment.
Although all the concepts discussed in the section 2.4,
2 and research using the methodology discussed in section
3.1, there were no positive results for the development of
technologies for OBPL treatment, which allows the conclusion
that professionals do not have specific devices for
performing a focused OBPL physical therapy and that the
development of these technologies could result in abbreviation
of patients recovering time and also the reduction of
residual deformities, these are the objectives that we hope
to achieve by using the training table proposed in this work.

4. Conclusions

The training table, proposed in this project, is an alternative

to conventional treatments that brings to a physical
therapist and patient a ludic technique capable of arousing
the interest of the child using a game as a treatment model.
The presence of light and sound and the presence of several
complexity levels make the exercise more interesting and
challenging. By the other hand, the computerized system
allows a better analysis of the patients progress throughout
the exercise sessions. Thus, the professional can accurately
assess the development of motor skills.

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