This prospective longitudinal study was conducted at the National Orthopaedic Rehabilitation Center of Mali (Centre National d’Appareillage Orthopédique du Mali [CNAOM]), the country’s main public referral institution for physical medicine, rehabilitation, and orthopaedic care.

The study was carried out from October 3, 2020, to December 31, 2023.

The target population consisted of children admitted to the functional rehabilitation unit of the CNAOM for obstetric brachial plexus palsy.

The following criteria were required for inclusion:

age between 0 and 5 years;clinically confirmed diagnosis of OBPP according to the Narakas classification;availability of complete medical records;regular participation in the rehabilitation program;informed parental consent.

The following patients were excluded:

children lost to follow-up after the initial evaluation;incomplete medical records;absence of standardized functional assessment.

The minimum sample size was calculated according to Cochran’s formula, assuming a 95% confidence level, an 8% margin of error, and an estimated prevalence of 50%. The minimum required sample size was 150 patients.

2.7.1. Primary Outcome

The primary outcome was functional recovery of the affected limb, as assessed by the global active movement scale.

2.7.2. Independent Variables

The following variables were investigated:

maternal age and parity;obstetric characteristics;mode of delivery;birth weight;delay between birth and diagnosis;Narakas classification;side of involvement.

Patients were evaluated at admission and subsequently after 3, 6, and 18 months of follow-up. Joint range of motion was measured using a standardized goniometer by experienced physiotherapists.

Motor function was graded on a scale ranging from 0 to 7, where:

0 indicated the absence of muscle contraction;7 indicated complete movement against resistance.

The severity of OBPP was classified according to the Narakas classification:

Narakas types I and II were considered partial lesions;Narakas types III and IV were considered complete lesions.

The rehabilitation program combined the following therapeutic interventions:

postural immobilization;passive mobilization exercises;sensory stimulation;electrical stimulation;progressively increasing active exercises.

The therapeutic strategy was individualized according to the child’s age and the severity of the neurological impairment.

Data were analyzed using SPSS software (version 22.0) and R statistical software.

Continuous variables were summarized using means, medians, and standard deviations, whereas categorical variables were expressed as frequencies and percentages.

Bivariate analyses were performed using Pearson’s chi-square test, Fisher’s exact test, or Yates’ continuity correction, as appropriate.

Multivariable logistic regression using generalized estimating equations (GEE) with an exchangeable correlation structure was performed to identify factors associated with functional recovery during follow-up.

Statistical significance was defined as a two-sided p-value below 0.05.

This study was based on routinely collected data obtained during the standard clinical management of patients. Verbal informed consent was obtained from parents or legal guardians before enrolment. Patient anonymity and data confidentiality were strictly maintained throughout the study.

During the study period, 28,939 admissions were recorded at the National Center for Orthopedic Rehabilitation of Mali (CNAOM), among which 1123 cases of obstetric brachial plexus palsy (OBPP) were identified, corresponding to a hospital frequency of 3.8%. A total of 150 children were included in the final analysis.

Maternal age ranged from 17 to 40 years, with a mean age of 28.4 ± 5.2 years. Most mothers had attended at least four antenatal consultations.

Dystocic deliveries accounted for 71.3% of cases, and instrumental extraction was performed in 24.7% of patients (Table 1, Figure 1).

Table 1.Distribution of mothers according to maternal age at delivery.

Figure 1.Distribution of mothers according to parity.

The median age at diagnosis was 4 months. Boys accounted for 57.3% of the study population (Table 2).

The median birth weight was 3765 g, and macrosomia was identified in 38.7% of newborns.

Partial Narakas lesions (types I and II) represented 56.7% of cases, whereas complete lesions (types III and IV) accounted for 43.3%.

After three months of follow-up, all children exhibited a motor score greater than 2 (Figure 2).

At the 18-month evaluation, most children demonstrated substantial functional improvement, with scores ranging from 6 to 7.

The overall recovery rate reached 78%, whereas 22% of children presented persistent motor sequelae.

Table 2. Distribution of all cases of obstetric brachial plexus palsy admitted during the study period and of the study cohort according to age.

Figure 2.Changes in recovery rates in the two groups.

Multivariate analysis revealed that the following factors were independently associated with better functional recovery:

partial forms of OBPP (adjusted OR = 3.86; 95% CI: 2.78 - 5.36; p < 0.001);maternal age below 35 years (adjusted OR = 2.30; 95% CI: 1.45 - 3.67; p < 0.001);primiparity (adjusted OR = 1.55; 95% CI: 1.08 - 2.21; p = 0.017);normal or low birth weight (adjusted OR = 1.75; 95% CI: 1.16 - 2.63; p = 0.007).

Conversely, complete Narakas lesions were associated with slower recovery and an increased risk of long-term functional sequelae.

Table 3.Factors associated with recovery in multivariate analysis.

Table 4.Analysis of factors associated with recovery using a generalized estimating equation (GEE) logistic regression model.

Direct admission: OR = 0.91 (95% CI: 0.66 - 1.26).

Community health centers: OR = 1.19 (95% CI: 0.73 - 1.95).

Referral health centers or university hospitals: OR = 1.06 (95% CI: 0.73 - 1.54).

Obstetrician-gynecologist: OR = 1.16 (95% CI: 0.80 - 1.67).

Figure 3.Forest plot of factors associated with recovery.

Figure 4.Visualization of changes in the predicted mean scores of global limb movement over time.