Letters to the Editor  |   July 2009
Brachial Plexus Injuries in Neonates
Author Affiliations
  • Benjamin M. Sucher, DO
    EMG Labs of Arizona Arthritis and Rheumatology Associates, Paradise Valley, Ariz
    Medical Director
Article Information
Neuromusculoskeletal Disorders / Pediatrics
Letters to the Editor   |   July 2009
Brachial Plexus Injuries in Neonates
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 347-348. doi:
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 347-348. doi:
To the Editor:  
I read with great interest—and also dismay—the February clinical practice article by David C. Mason, DO, and Carman A. Ciervo, DO,1 regarding the use of osteopathic manipulative treatment (OMT) for neonates with brachial plexus injuries. 
In the “Treatment Options” section of their article, Drs Mason and Ciervo1 do not readily distinguish “muscle strains” from plexopathy. I fear that such lack of clarity could mislead the reader. 
Moreover, in the “Osteopathic Manipulative Treatment” section of the article,1 I was concerned by the authors' citation and application of three articles that I wrote on the treatment of adults with thoracic outlet syndrome (TOS).2-4 
It must be clearly understood that brachial plexus injuries in neonates are not considered a form of TOS. Drs Mason and Ciervo1 are correct to note that “the etiologic processes involved in thoracic outlet syndrome and neonatal brachial plexus injuries are clearly different.” In fact, the diagnosis of neonatal brachial plexus injuries relies on observation of substantial loss of limb function,5 which is quite the opposite of conditions typically seen in patients with TOS. The primary patho-physiologic condition that characterizes TOS is a chronic mild compression, whereas brachial plexus injury in neonates involves acute stretch disruption of axons from traction.5 The latter injury does not result in tight tissues amenable to myofascial release, but requires relative rest and time for axonal regeneration. Any aggressive OMT maneuvers to release the thoracic outlet in a neonate would inherently risk further irritation or disruption of already injured and fragile axons. Thus, such maneuvers need to be avoided at all costs in neonates. 
It is unfortunate that Drs Mason and Ciervo1 suggest applying the myofascial release approach I described for adults with TOS to neonates who have the Erb-Duchenne type of paralysis (ie, brachial plexus injuries). The approach described for adults with TOS was never intended for use in neonates with brachial plexus injuries. The initial description of the form of TOS covered in my article on pathology and diagnosis2 specified that the patients in these cases had no documented nerve injuries. Many of the cases were considered “disputed” or “nonspecific neurogenic” TOS, because—despite persistent symptoms—no nerve damage could be demonstrated, and most electromyographic examinations produced normal results.2 
It is also disturbing that Drs Mason and Ciervo1 characterize my manual approach as “gentle myofascial stretching.” Nothing could be further from an accurate description of the type of OMT that I used, which I described as an “aggressive...powerful form of myofascial release manipulation and stretching.”2,3 There is nothing gentle about these techniques, which are expected to produce substantial discomfort in the patient as part of the release process. 
The manual approach I described in my article on treatment3 involved “deep myofascial release” and “vigorous, controlled stretch” maneuvers that “require greater stretching break up adhesions.” These maneuvers are designed to be applied to adults who can provide immediate verbal feedback regarding possible effects of treatment, such as numbness or tingling and perceived discomfort. Such verbal feedback, which is essential for the operator to optimally monitor response to treatment, would obviously be lacking in the neonate population. Furthermore, these maneuvers typically irritate the neurovascular structures of patients and would be harmful when applied to nerve tissues that are already damaged—as in neonates with brachial plexus injuries. The maneuvers are intended to treat patients with irritative forms of TOS—not the true neurogenic form. 
In conclusion, I advise exercising extreme caution in any attempts to apply vigorous OMT to neonates, whether these individuals have documented nerve injuries or not. The treatment approach to TOS is completely different from the treatment approach to neonatal brachial plexus injury—and this difference needs to be recognized. 
Mason DC, Ciervo CA. Brachial plexus injuries in neonates: an osteopathic approach. J Am Osteopath Assoc. 2009;109:87-91. Available at: Accessed April 10, 2009.
Sucher BM. Thoracic outlet syndrome—a myofascial variant: part 1. Pathology and diagnosis. J Am Osteopath Assoc. 1990;90:686-696,703-704.
Sucher BM. Thoracic outlet syndrome—a myofascial variant: part 2. Treatment. J Am Osteopath Assoc. 1990;90:810-812,817-823.
Sucher BM, Heath DM. Thoracic outlet syndrome—a myofascial variant: part 3. Structural and postural considerations [published correction appears in J Am Osteopath Assoc. 1993;93:649]. J Am Osteopath Assoc. 1993;93:334 ,340-345.
Wilkins KE. Special problems with the child's shoulder. In: Rockwood CA, Matsen FA. The Shoulder. Philadelphia, Pa: WB Saunders Co; 1990:1033-1087.