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Disabil Rehabil, Early Online: 1–7! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.972578

RESEARCH PAPER

Explaining daily functioning in young adults with obstetric brachialplexus lesion

Conny de Heer1, Heleen Beckerman1,2, and Vincent de Groot1,2

1Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The Netherlands and 2EMGO Institute for Health and Care

Research, VU University Medical Center, Amsterdam, The Netherlands

Abstract

Purpose: To study the influence of obstetric brachial plexus lesion (OBPL) on arm–hand functionand daily functioning in adults, and to investigate the relationship of arm-hand functionand pain to daily functioning. Method: Adults with unilateral OBPL who consulted the brachialplexus team at the VU University Medical Center in the past were invited to participate. Dailyfunctioning was measured with the Disability of the Arm, Shoulder and Hand (DASH)questionnaire and the SF36, pain with VAS Pain Scales and arm-hand function with the NineHole Peg Test (9-HP-test) and the Action Research Arm Test (ARAT). Scores of the affected armwere compared to those of the non-affected arm or norm values for healthy controls. Results:Twenty-seven persons (mean age 22, SD 4.2 years), of whom 10 men, participated. The ARATand 9-HP-test scores for the affected arm were significantly worse than those for the non-affected arm. Moderate to severe pain in the affected arm, the non-affected arm or the backwas reported by 50% of the participants. The DASH general, sports/music and SF36 physicalfunctioning scores were significantly worse than norm values. The ARAT/9-HP-test and dailyfunctioning showed little association. Low to moderate associations were found between painand daily functioning. Conclusions: Many young adults with OBPL experience limitations in dailyfunctioning. Pain, rather than arm-hand function, seems to explain these limitations.

� Implications for Rehabilitation

� Obstetric brachial plexus lesion (OBPL) is caused by traction to the brachial plexus duringlabour, resulting in denervation of the muscles of the arm and shoulder girdle.

� Adults with OBPL are hardly seen in rehabilitation medicine.� This study shows that many young adults with OBPL experience limitations in daily

functioning. Pain, rather than arm-hand function, seems to explain these limitations.� Fifty percent of the participants complained about moderate or severe pain, which was

located in the affected arm, the back and the non-affected arm. There seems an age-relatedincrease in pain prevalence.

� Persons who had undergone plexus surgery had a significantly worse arm-hand function, butcomparable scores on daily functioning scales compared to persons without plexus surgery.

� When limitations in daily functioning or pain occur, referral to a rehabilitation physician isindicated.

Keywords

Obstetric brachial plexus lesion, pain,participation, quality of life, work,young adults

History

Received 19 February 2014Revised 22 September 2014Accepted 30 September 2014Published online 21 October 2014

Introduction

Obstetric brachial plexus lesion (OBPL) is caused by tractionto the brachial plexus during labour, when the upper shoulderis blocked at the symphysis. Additional traction to the child’shead further stretches the brachial plexus, resulting in (partial)denervation of the muscles of the arm and shoulder girdle.The brachial plexus is composed of the lower four cervical nerveroots (C5–C8) and the first thoracic nerve root (Th1). The upper

brachial plexus is most commonly affected. In C5–C6 injury,as first described by Erb and Duchenne, paresis of thesupraspinatus, infraspinatus, deltoid and biceps muscles isobserved. Injury to C7 causes involvement of wrist and fingerextensor muscles, while injury to C8–T1 impairs hand function.Isolated injury to the lower plexus as described by Dejerine–Klumpke is rare. The severity of nerve damage ranges fromneurapraxia (stretching of the nerve) and axonotmesis (rupture ofsome axons) to neurotmesis (rupture of the entire nerve) andavulsion of roots from the spinal cord.

The incidence of OBPL has been reported to be 1.6–4.6 per1000 live births in hospital-based and population-based studies[1–5]. Although a slight decrease in incidence in US hospitals was

Address for correspondence: Mrs Conny de Heer, Department ofRehabilitation Medicine, VU University Medical Center, PO Box 7057Amsterdam 1007 MB, Netherlands. E-mail: connydeheer@gmail.com

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reported from 1.7 to 1.3/1000 over the period 1997–2003 [2],recent European studies have shown higher incidence rates [1–5]and an increasing annual incidence from 1.7 to 3.3/1000 overthe period 1987–2007 [3,4]. Explanations for these differingtrends probably relate to the percentage of caesarean sections, thenumber of babies with a high birth weight (macrosomia4 4 kg),frequencies for multiple births and the rates for pre-term labourinduction.

Complications due to OBPL

‘‘Spontaneous recovery’’ ranges from 66% to 92% and isdependent on the definition used [6,7]. Two reviews havehighlighted the lack of methodologically sound research onrecovery following OBPL, and trends to complete recovery areprobably lower than is often suspected [8,9]. In one review,Pondaag et al. found rates in prospective studies of 70-80% forspontaneous, complete recovery [8]. Foad et al. [9] supported thisfinding and noted a higher tendency for recovery followinginjury to C5–C6 and C5–C7. The remaining children hadpermanent nerve damage with impaired function of the shoulder,arm and hand.

Primary and secondary healthcare professionals (e.g. paedia-tricians, paediatric physiotherapists) should refer a child with anincomplete recovery from OBPL to a plexus team neurosurgeon,preferably before the age of 3 months, to determine whetherbrachial plexus reconstruction is indicated. Microsurgery forOBPL has been developing since 1990, and criteria have beendeveloped to determine whether neurosurgery is necessary[8,10,11]. The following criteria are currently in use: no recoveryof m. biceps brachii function, regardless of whether in combin-ation with failure to recover extension of the wrist, fingers andthumbs within 3 months, evidence of Horner’s sign, persistenthypotonic paralysis, persistent phrenic nerve paralysis, severesensory disturbances, evidence of root avulsions on MRI or CT,persistent denervation in neurophysiological studies. When one ormore of these criteria are met, exploration of the brachial plexusshould be performed at the age of 4–6 months [8,10,11].

At this young age, the main goal of the plexus team is tocreate favourable (developmental) conditions that will facilitateoptimal functioning and participation for these children laterin life [12]. Shoulder contractures and glenohumeral deformitiesmay occur as a secondary complication of OBPL, and aninternal rotation contracture with a posterior subluxation of thehumeral head occurs especially frequently [13]. During child-hood, the prevalence of shoulder contractures and glenohumeraldeformity is 56 and 33%, respectively [14]. When shoulderpathology has developed, secondary orthopaedic surgery such as atendon transfer or humeral derotating osteotomy is common,while secondary surgery on the elbow, wrist and hand is lessfrequent [15].

Daily functioning

Research on the course of activities of daily living (ADL) hasbeen mainly carried out in children. Hoeksma et al. [7] reportedADL limitations in 12% of children at an average age of 3 yearsand 10 months. In a cross-sectional study in 7- to 8-year-oldchildren with an OBPL, nearly 40% experienced difficulties withwriting and more than 45% complained of musculoskeletalpain [16]. In the same children, restrictions on participationwere less pronounced [16]. In a follow-up study of childrenwith OPBL after neurosurgery, 31% of the children (average age13.5 years) had pain that was not associated with the type oflesion or shoulder pathology, except clavicular non-union [17]and 35% of these adolescents needed help with ADL [17].Strombeck and Fernell [18] reported ADL limitations in 25% of

children and adolescents aged between 7 and 20 years. Theproblems reported were, in particular, two-handed activities oractivities in which the non-affected side could not be reached bythe affected arm. Adolescents who were most affected showedless confidence during motor activities compared to the mildlyaffected and healthy individuals [18]. These adolescents alsoexperienced problems with daily activities at 3–4 times greaterfrequency and expressed more concern about their health.

There is currently little research available on the consequenceson daily functioning of adults with OBPL. We are only awareof the published study among adult members of the Erb’sPalsy Group UK, and one unpublished abstract [19,20]. Partridgeand Edwards reported pain in the majority of adult members ofthe Erb’s Palsy Group UK (92%), and 85% indicated that the painwas getting worse [19]. ADL limitations were reported by 80% ofthe adults [19]. However, Van der Velden et al. reported thatquality of life is not negatively affected by OBPL [20].

As rehabilitation physicians rarely see adults with OBPL,this physician group has relatively little experience with thesepatients. There are several possible explanations for this situation:adults with an OBPL may experience few or no limitations, orthey may have found a way of adapting to the complications ofOBPL without resorting to help from a rehabilitation physician.Alternatively, it is possible that adults with an OBPL experienceproblems but are unaware of the possibilities of rehabilitationmedicine. Studies by Kirjavainen et al. [17], Strombeck andFernell [18] and Partridge and Edwards [19] all provided evidencefor the latter explanation.

This study was performed to broaden our knowledge of thegeneral functioning of adults with OBPL. The aims of the studywere to investigate the influence of OBPL on arm-hand functionand daily functioning in adults, and to investigate the relationshipof arm-hand function and pain to daily functioning.

Methods

Participants

The Netherlands has three clinics for the tertiary care of childrenand adults with injuries of the brachial plexus in, respectively, theAtrium Medical Center, Heerlen, Leiden University MedicalCenter (LUMC) and the VU University Medical Center (VUmc),Amsterdam. In these clinics, the departments of neurosurgery,rehabilitation medicine, orthopaedics, plastic and reconstructivesurgery, physical therapy and occupational therapy workclosely together in specialised multidisciplinary brachial plexusteams.

Patients with OBPL who consulted the brachial plexus teamat the VUmc in the past were invited to participate by letter.If there was no response within 4 weeks, they were contactedby phone. If the address and phone number were incorrect, theirgeneral practitioner was asked to invite them to participate. Theinclusion criteria were: adults with unilateral OBPL, aged 18–65years, able to understand the Dutch language. The exclusioncriterion was a co-morbid central neurological disorder.

The registration of diagnostic codes at the VUmc from theearly 1990s onwards allowed us to identify 64 adult patientswith OBPL. Two were excluded: one due to additional cerebralpalsy and the other due to double-sided OBPL. Sixty-twopersons (26 females and 36 males) were approached (Figure 1).Nine were untraceable as their address and telephone numberwere incorrect and they changed GP, seven failed to respond toletters sent to the correct address and 16 persons were notinterested or did not have time to participate. Thirty patientsexpressed interest, of whom 27 finally participated. One personcompleted questionnaires but did not participate in the physicalexamination tests due to personal reasons.

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The medical ethics committee of the VUmc approved the studyand written informed consent was obtained from all participantsprior to testing.

Measurements

Participants completed self-reported questionnaires and a physicalexamination was conducted at the outpatient rehabilitationclinic. Arm-hand function was measured using the modifiedMallet score [21], the Action Research Arm Test (ARAT) [22]and the Nine Hole Peg Test (9-HP-test) [23]. The modifiedMallet score [21] measures abduction, external rotation,placing the hand behind the neck, placing the hand as high aspossible on the back and lifting the hand to the mouth andclassifies these shoulder functions. The ARAT [22], whichconsists of 19 tasks, was used to assess manual dexterity ofthe affected and the unaffected arm. The participant is asked tograsp, move and release objects of different sizes and shapesand to perform three gross movements. Each task is scored on a4-point scale, ranging from 0 (no part of the action can beperformed) to 3 (the action is performed completely andwithin the time limits). The maximum score is 57, indicatingnormal movement of the arm. The reliability and validity of theARAT have been confirmed for unilateral arm-hand functionproblems in stroke patients [22]. The 9-HP-test [23] was used tomeasure finger dexterity. Nine pegs have to be placed in a peg-board one-handed, while the time is monitored with a stopwatch.This test was performed twice with each hand and the best timescore was used. The reliability of the 9-HP-test has beenconfirmed [23].

Pain was measured with 10 cm visual analogue scales (VAS)for pain in the affected and unaffected shoulder, elbow, wrist/handand the back, respectively. Daily functioning, i.e. the perceived

performance of activities of daily living, household, work andleisure activities, was examined with the disability of the armshoulder and hand (DASH) questionnaire and the medicaloutcome study short form general health survey (SF36) [24,25].The DASH addresses functional limitations in daily activitiesdue to shoulder, arm or hand problems and consists of themodules general functioning, work and sports/music. The workand sports/music modules are optional, and each modulestarts with a skip-and-fill question regarding the current job(including housewife) and most important sports activity ormusic instrument, respectively. Every DASH module wasscored so that 0 represents the least disability or best health and100 the most disability or worst health. The SF36 addressesthe quality of life with eight domains: physical functioning,role functioning physical, role functioning emotional, socialfunctioning, bodily pain, mental health, vitality and generalhealth [25]. Sum scores are calculated with a maximum of 100,meaning the best possible quality of life. The SF36 bodily painand three DASH items (D24, D25 and D28) also measure aspectsof pain.

Analysis

The results of the DASH were compared with the referencevalues for healthy individuals from the United States generalpopulation, derived from the National Family Opinion throughthe American Academy of Orthopaedic Surgeons [26]. The age-matched subgroup (19–34 years) median score was 2 (interquar-tiles 0 and 6) [27]. The outcomes of the SF36 were comparedwith reference data for healthy Dutch peers aged 16–40 years[25]. The non-parametric one-sample binomial test was used totest for statistical significant differences with reference datainstead of z-scores [28]. Due to the skewness of the absolutescores of our small study population on most of the DASHmodules and SF36 domains, transformation to z-scores would alsoresult in skewed frequency tables. Therefore, we used a non-parametric binomial test, which compares the number of patientswith a score worse than the mean or median of the referencepopulation to the number of patients with a better score.

Results of the affected arm, derived from the ARAT, the9-HP-test and the VAS pain scales were compared to the scoresfor the unaffected arm using the non-parametric paired samplesWilcoxon signed-rank test. The VAS pain scales were alsotransformed into a 4-point scale, with a score of 30–53 indicatingmoderate pain and a score higher than 54 indicating severe pain[29]. Spearman correlation coefficients were used to analysethe relationship of VAS pain scales and arm-hand function withdaily functioning. Munro’s correlation descriptors were usedto interpret the correlation coefficient as very low: 0.15–0.24;low: 0.25–0.49; moderate: 0.50–0.69; high: 0.70–0.89; or veryhigh: 0.9–1.0 [30]. Non-parametric tests were used as the datawere not normally distributed. p Values of50.05 were consideredstatistically significant. Statistical analyses were performed usingStatistical Product and Service Solutions Version 20 (SPSS Inc.,Chicago, IL) for Windows.

Results

Participants

Twenty seven young adults (17 females and 10 males)participated. Ages ranged from 18 to 34 years, with a meanage of 22.5 years. Thirteen participants were affected on theleft side and 14 on the right side. Three participants hadundergone plexus surgery, three had undergone plexus surgeryand orthopaedic surgery and eight had undergone orthopaedicsurgery only (Table 1).

Figure 1. Flow chart.

DOI: 10.3109/09638288.2014.972578 Explaining daily functioning in adults with OBPL 3

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Arm-hand function

The modified Mallet showed that the majority of participants hadsevere impairments in global abduction (65.4%) and externalrotation (53.8%) of the affected arm (Table 1). The outcomes onthe ARAT and 9-HP-test are summarised in Table 2. All 26participants reached the maximum ARAT score of 57 with theirnon-affected arm. The scores of the total ARAT and all fourdomains of the affected arm were significantly worse than thescores for the non-affected arm. The worst scores were foundon the grasp and pinch tasks. These tasks involve moderate toheavy lifting skills and fine motor skills, respectively. Fingerdexterity, as measured with the 9-HP-test, was also signifi-cantly worse on the affected side (Table 2). The statistics of the9-HP-test scores were based on 23 participants, because intotal three persons were unable to complete the test with theiraffected arm.

Among the tested participants, six had undergone plexussurgery. Their affected arm function on the ARAT was signifi-cantly worse (median 30 points) than the median for theremaining 20 participants (56 points). Two participants wereactually unable to perform the 9-HP-test using their operatedarm. The median score of the 9-HP test of the affected hand ofthe remaining four participants was 52.5 s, compared to a medianscore of 20.9 s in 19 participants without plexus surgery(p¼ 0.019).

Pain

VAS pain scores for the shoulder and elbow were significantlyworse on the affected side. The median score for back pain wasthe worst, although a general population-based back pain scorewas not available for comparison. Combining all transformedVAS pain scales, 50% of the participants reported moderateor severe pain [29] (Table 3). Additional information fromindividual DASH questions showed that 54% of the participantshad mild to moderate pain in their arm, shoulder or hand in thepreceding week, 63% had mild to moderate pain during activitiesin the preceding week and 19% reported pain during sleep.However, the SF36 bodily pain scores of the 27 adults with OBPLwere slightly better than the reference data of age-matched Dutchpeers (Table 3).

Daily functioning

The optional module DASH work was completed by 19 partici-pants, while 18 participants completed the DASH sports/music(Table 4). Scores on the DASH general and DASH sport/music,but not DASH work, were significantly worse than the normvalues (p¼ 0.000; p¼ 0.008, respectively). Of the eight SF36domains, the score for the SF36 physical functioning was theonly one that was significantly worse than that of age-matchedDutch peers (p¼ 0.021).

There were only small, non-significant differences betweenthe participants with and without plexus surgery with regard todaily functioning.

Explaining daily functioning

To investigate whether daily functioning could be explained byimpaired arm-hand function or pain in the arm or back, Spearmancorrelation coefficients were calculated (Tables 5 and 6).

As shown in Table 5, the correlation coefficients of the ARATand 9-HP-test with the DASH general, work and sports/musicwere low to very low and varied between �0.346 for ARAT totalwith DASH sports/music to 0.183 for ARAT pinch with DASHwork. With respect to the VAS pain scales, most correlationcoefficients with the DASH were higher. The highest correlationswere found for pain in the affected shoulder with DASH work(0.704), and back pain with DASH general (0.622), DASH work(0.444) and DASH sports/music (0.548). Pain in the affected armexplained up to 17% of DASH general.

In addition, the highest correlations for the SF36 weregenerally found with the pain scales and were lower for theARAT and 9-HP-test (Table 6). More pain often resulted in worsescores on SF36 mental health, SF36 role functioning due toemotional problems and SF36 social functioning. Pain in theaffected arm and back also resulted in worse scores on the SF36physical functioning, explaining a maximum of 27% of the SF36physical functioning scores.

Discussion

This study of young adults with OBPL showed that their dailyfunctioning in general and in leisure time (sports and playing a

Table 1. Demographic and OBPL characteristics of 27 participants.

N %

Patient characteristicsAge (years), mean (SD) 22.5 (4.2)Gender

Male 10 37.0Female 17 63.0

WorkFull-time job 4 14.8Part-time job 3 11.1Student 17 63.0No work/study 3 11.1

OBPL characteristicsSide of injury

Left 13 48.1Right 14 51.9

Severity of injuryPartial OBPL 26 96.3Unknown 1 3.7

Mallet scorea

Global abduction530� 1 3.930–90� 16 61.5490� 9 34.6

Global external rotation0� 9 34.6520� 5 19.2420� 12 46.2

Hand to neckImpossible 5 19.2Difficult 16 61.6Easy 5 19.2

Hand to backImpossible 4 15.4S1 8 30.8Th12 14 53.8

Hand to mouthTrumpet sign 11 42.3Partial trumpet sign 3 11.55 40� abduction 12 46.2

Surgical interventionsNo 13 48.1Plexus surgery 3 11.1Plexus surgery and orthopaedic surgery 3 11.1Orthopaedic surgery 8 29.7

Comorbidityb

Yes 6 22.2No 21 77.8

aOne missing physical examination.bComorbidity: diabetes (n¼ 2), asthma (n¼ 2), headache/migraine

(n¼ 2), Swyer–James syndrome (n¼ 1), irritable bowel syndrome(n¼ 1) and throat/nose/ear problems (n¼ 1).

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musical instrument) was worse than that of healthy age-matchedpeers. Both findings are in line with previous studies in childrenand adolescents with OBPL [17–19]. Scores on the SF36 onlydiffered significantly from healthy peers for the SF36 physicalfunctioning. The arm-hand function of the affected arm, asmeasured with the ARAT and the 9-HP-test, was significantlyworse than the unaffected arm. Arm-hand function only slightlyexplained daily functioning. The scores on the DASH and SF36could be better explained by pain and less so by the ARAT and9-HP-test scores.

In this study, we tested arm-hand function of the affectedand non-affected arms separately using the ARAT. However,the ARAT has not yet been validated in adults with OBPL.All participants reached the maximum score of 57 with theirnon-affected arm, while seven participants also reached themaximum score with their affected arm, and an additional fivescored 56 points with their affected arm. As the ARAT allows arelatively long-time period for completion of each task beforethe score is affected, another instrument may better portray thequality of arm and shoulder movements and the use of compen-satory strategies when using the affected arm. A bilateral arm andhand function test in particular would be more suitable in thispatient population [31].

Nineteen participants completed the DASH work and experi-enced the same work-related complaints and limitations comparedto the age-matched general population. Also, on the DASHgeneral item 23, only three persons reported current limitations inwork and other daily activities. Of our study population, 7 of the27 participants had a part-time or full-time job as their main daily

occupation, and one participant received a complete disabilitypension. The majority of participants were in full-time education,and mainly completed the DASH work module based on theiradditional job. In the Netherlands, it is very common that studentshave a part-time job. Apparently, these young adults with OBPLwere guided by their arm and hand possibilities when choosingwork. This might explain why a significant difference on theDASH work was not found. It is conceivable, however, that theparticipants will experience greater work-related problems laterin life, for instance due to adverse effects of compensatorymovement strategies adopted. Longitudinal research in adoles-cents and young adults with OBPL should focus on the choice ofeducation and future career and the physical constraintsassociated with ageing.

The prevalence of moderate to severe pain (50%) in ourparticipants is high [29]. Compared to other studies of personswith OBPL, that mentioned pain in 45% of 7–8 years old [16] and92% of adults with an average age of 39.5 years [19], there seemsan age-related increase in pain prevalence. Moreover, most of theparticipants of the latest study reported that their pain was gettingworse across time [19]. Nine young adults complained about pain

Table 3. VAS pain scores of 26 young adults with OBPL transformed intoa four-point scale [29].

VAS (mm)None(0–4)

Mild(5–29)

Moderate(30–53)

Severe(54–100)

ShoulderAffected 5 11 5 5Non-affected 17 8 – 1

ElbowAffected 16 6 3 1Non-affected 22 2 1 –

Wrist/handAffected 14 8 3 1Non-affected 19 4 2 1

Back 9 10 4 3

Table 2. Arm and hand function and VAS pain scores of 26 young adultswith OBPL.

Affected side Non-affected side p Valuea

Median (min–max) Median (min–max)

ARATTotal 54 (12–57) 57 (57–57) 0.000b

Grasp 18 (1–18) 18 (18–18) 0.002b

Grip 11 (2–12) 12 (12–12) 0.000b

Pinch 17.5 (0–18) 18 (18–18) 0.001b

Gross movement 9 (3–9) 9 (9–9) 0.003b

9-HP-Test (s) 21.72 (16.88–208.25) 18.90 (15.28–24.81) 0.001b

VAS pain (cm)Shoulder 1.70 (0–7.20) 0 (0–5.90) 0.000b

Elbow 0.15 (0–8.20) 0 (0–3.30) 0.021b

Hand/Wrist 0.35 (0–7.10) 0 (0–8.30) 0.107Back 1.95 (0–8.40) NA NA

9-HP-test: n¼ 23.aPaired samples Wilcoxon signed-rank test.bSignificant p value (50.05).NA¼ not applicable.

Table 4. DASH and SF36 scores of 27 young adults with OBPL.

Median (min–max) Norm values p Valuea

DASHGeneral (n¼ 27) 16.4 (1.7–47.5) 2 0.000b

Work (n¼ 19) 0.0 (0–56.3) 0 1.000Sports/music (n¼ 18) 21.9 (0–50.0) 0 0.008b

SF36Physical functioning 85.0 (50.0–100) 93.1 0.021b

Role functioning physical 100 (0–100) 86.4 0.690Role functioning emotional 100 (0–100) 85.4 0.108Social functioning 87.5 (25.0–100) 87.8 0.700Bodily pain 84.7 (12–100) 80.9 1.000Mental health 72.0 (40.0–100) 78.7 0.441Vitality 65.0 (30.0–95.0) 70.7 0.441General health 75.0 (35.0–100) 78.2 0.700

aOne-sample binomial test.bSignificant p value (50.05).It should be noted that the scores of the DASH and SF36 go in the

opposite direction, i.e. 100 is most disability for DASH and bestpossible quality of life for SF36.

Table 5. Spearman correlation coefficient of arm-hand function and painwith the DASH.

DASH general DASH work DASH sports/music

ARATTotal �0.087 0.068 �0.346Grasp �0.094 0.143 �0.108Grip 0.000 �0.093 �0.257Pinch �0.057 0.183 �0.217Gross movement �0.132 �0.131 �0.153

9-HP-testAffected arm 0.086 �0.043 �0.085

VAS pain scalesShoulder

Affected 0.362 0.704a 0.357Non-affected 0.369 0.158 0.076

ElbowAffected 0.389a 0.073 0.293Non-affected 0.128 �0.211 0.318

Wrist/handAffected 0.415a 0.131 0.200Non-affected 0.073 �0.194 0.406

Back 0.622a 0.444 0.548a

aSignificant correlation coefficients (p value50.05).

DOI: 10.3109/09638288.2014.972578 Explaining daily functioning in adults with OBPL 5

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in their non-affected arm, which might be caused by compensa-tory use of this arm leading to increased strain, or by involuntarychanges of left- or right-handedness [16]. Furthermore, it isunclear whether there is an association between pain and shoulderdeformity. Further longitudinal cohort studies in adolescents andyoung adults should also focus on the relationship between painand degenerative joint changes across time. More research is alsoneeded on the most effective treatment to reduce shoulder pain inpatients with OBPL.

The following limitations of our study should be mentioned.First, our participants were recruited from a database maintainedby a specialised plexus team and not from the general population.Therefore, participants who were more seriously affected and/orshowed poorer recovery might have been preferentially included.This limits the generalisation of our results to this specific patientpopulation. Second, the relatively recent start of registration ofpatients with OBPL resulted in the recruitment of young adultswith an average age of 22.5 years. Third, of the 62 patients whowere initially approached, only 27 participated. This may haveresulted in a selection bias, perhaps indicated by the fact that 37%of the mainly male non-participants had undergone plexus surgeryin the past, as compared to 22% of the participants. Finally, thecross-sectional design of our study does not allow inferencesregarding a possible causal relationship between pain, arm–handfunction and daily functioning.

In conclusion, daily functioning is worse in young adults withOBPL than in healthy peers. ARAT and the 9-HP-test make only aminor contribution to explaining this finding. Pain appears to bean important contributing factor. When young adults with OBPLexperience limitations in daily functioning and pain, referral to arehabilitation physician may be indicated.

Acknowledgements

We wish to thank the patients who participated in this study. Themanuscript was edited by JP Bayley PhD, biomedical editor(www.medactie.com).

Declaration of interest

The authors report no declarations of interest. This researchreceived no specific grant from any funding agency in the public,commercial or not-for-profit sectors.

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Table 6. Spearman correlation coefficients of arm-hand function and pain with the SF36.

SF36 PF SF36 RP SF36 RE SF36 SF SF36 BP SF36 MH SF36 VT SF36 GH

ARATTotal 0.055 �0.238 0.353 0.225 �0.003 0.382 0.093 �0.020Grasp 0.151 �0.352 0.285 0.187 �0.055 0.377 0.111 �0.002Grip 0.006 �0.221 0.281 0.073 0.040 0.274 0.085 �0.094Pinch 0.090 �0.317 0.334 0.235 �0.003 0.407a 0.200 0.040Gross movement �0.064 �0.095 0.504a 0.190 0.061 0.241 0.146 �0.173

9-HP-testAffected arm 0.287 �0.035 �0.447a �0.241 0.051 �0.215 0.046 0.147

VAS pain scalesShoulder

Affected �0.420a �0.269 �0.288 �0.018 �0.158 �0.525a �0.108 �0.250Non-affected �0.111 �0.145 �0.600a �0.476a �0.423a �0.581a �0.427a �0.220

ElbowAffected �0.520a �0.335 �0.101 �0.314 �0.520a �0.148 �0.317 �0.063Non-affected �0.006 �0.172 �0.423a �0.402a �0.199 �0.680a �0.281 �0.231

Wrist/handAffected �0.289 �0.236 �0.126 �0.419a �0.398a �0.550a �0.290 �0.483a

Non-affected �0.186 �0.100 �0.290 �0.517a �0.279 �0.466a �0.430a �0.606a

Back �0.374 �0.274 �0.432a �0.471a �0.522a �0.281 �0.145 �0.269

aSignificant correlation coefficients (p value5 0.05).

6 C. de Heer et al. Disabil Rehabil, Early Online: 1–7

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DOI: 10.3109/09638288.2014.972578 Explaining daily functioning in adults with OBPL 7

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