"Life-saving...I don't know what it would be other than that."

At birth, Miah Tobin's right arm and hand were paralyzed. Referred to the Brachial Plexus Center at Cincinnati Children's Hospital Medical Center, Miah was diagnosed with a brachial plexus injury consisting of nerve damage to her upper and middle plexus.  

When Miah Tobin was born with a limp arm, nobody seemed to have an explanation for its lifelessness. X-rays taken following her birth showed no broken bones, and her family went home without knowing why Miah's right arm was paralyzed. As her family spent the next few months searching for information about this problem, Miah's condition appeared to get worse as her arm straightened and rotated internally, her hand clenched into a fisted position and her wrist was constantly bent.

Unable to diagnosis the problem, Miah's pediatrician referred the family to a neurologist, who suggested that Miah see a physical therapist. It was this meeting with the physical therapist at Cincinnati Children's Outpatient Anderson that altered the course of Miah's life. Recognizing symptoms consistent with brachial plexus birth palsy, the physical therapist recommended Miah visit the Brachial Plexus Center at Cincinnati Children's. There she would be examined by a multidisciplinary team of experts on this common, yet not well-known, birth injury.

The brachial plexus is a network of nerves that provides movement and feeling to the shoulder, arm and hand. The cause of a birth brachial plexus injury is usually due to an overstretching of nerves in the neck during the birth process.

Miah Tobin playing dress-up with her sister. 

Miah Tobin enjoys playing dress-up with her older sister, Michaelah 

At three months old, Miah was evaluated at the Brachial Plexus Center by Kevin Yakuboff, MD, Plastic and Reconstructive Surgery; Linda Michaud, MD, Physical Medicine and Rehabilitation; and Allison Allgier, Occupational Therapy. The team diagnosed Miah with upper and middle brachial plexus damage, and immediately designed an individualized treatment plan for Miah that involved both surgery and therapy. Tonya Holman, Miah's mother, believes that this set into motion a series of experiences with Cincinnati Children's that proved to be "life-saving. I don't know what it would be other than that."

Miah Undergoes Surgery

Because brachial plexus injuries involve nerve damage, Miah needed surgery right away to prevent permanent loss of function in her arm and hand.  Miah's EMG and MRI tests confirmed the doctors' diagnosis that the nerves of her upper and middle plexus were severely damaged. Two weeks after her clinic visit, Miah underwent primary nerve reconstructive surgery.

During the surgery, Dr. Yakuboff grafted five of Miah's sural nerves (nerves found in the leg) and replaced the damaged nerves in her neck to stimulate re-growth, as well as removed scar tissue that had been blocking nerve signals. After the surgery, Miah was placed in a brace. Once the dressings were removed, Miah began occupational therapy once a week. Because nerves grow at a rate of one inch per month, it was over a year before Miah's family noticed significant improvements in her ability to lift her shoulder, bend her elbow and use her hand. Over time, she was able to move her fingers, something she could not do before the surgery. Miah continued to be seen every three months at the Brachial Plexus Center and maintained physical and occupational therapy visits weekly.

At three years old, Miah arrived at Cincinnati Children's for another surgery: arthroscopic-release and tendon-transfer on her shoulder. Charles Mehlman, DO, pediatric orthopaedic surgeon and co-director of the Brachial Plexus Center, performed the procedure.

The highlight of Miah's visit occurred before the surgery when her nurse, Simon, asked if he could see the doll she had brought with her. Simon proceeded to wrap the doll's arm in a pink cast, the same color Miah had picked to wear after her surgery. Miah's mom says that Simon's support was absolutely wonderful. "Miah's response to Simon was unbelievable. She ran right up to him and I could tell she was thinking 'this man is the coolest.' He offered her a popsicle and talked to her with respect and interest," Tonya said. "He went way beyond what he was required to do for Miah and his efforts paid off for her. It was incredible."

Miah combing the hair on her toy pony. 

Miah's family also appreciated the help Trauma Services provided in coordinating car seat options for them following the surgery. Because of the cast, Miah needed a specially designed car seat. "Without that I don't know what we would have done. She was so little and still needed the five-point harness," Tonya said. "It's something I would never have thought about beforehand but it is such an important detail to have worked out before the surgery."

A Positive Lesson in Life

Miah's arm was put in a brace for six weeks. Miah disliked the brace and didn't understand why she had to wear it, but her mother believes it taught her a positive lesson in life in determination and the rewards of hard work.

After spending her first several sessions kicking and screaming in protest of her exercises, Miah eventually realized that she was going to have to do them and began to focus on getting through the program as quickly as possible. "The brace became a motivational tool for her to do her occupational therapy exercises because she knew that if she wanted the brace off, she was going to have to do her exercises," Tonya said. "She became determined to do what she had to do and get through it."

Her family celebrated her "Brace Off Day" by going to the park to play. They immediately noticed a huge improvement in her range of motion and use of her arm and hand. Before the surgery, Miah's arm was internally rotated. Now, her arm is externally rotated where she can use her right hand to pick things up and hold them.

"Her injury doesn't slow her down at all."

Miah can do things she couldn't do before her surgeries. "Her injury doesn't slow her down at all," said Stephen Holman, Miah's stepfather.

While in the waiting room for another visit at the Brachial Plexus Center, Miah's mom witnesses a poignant moment when Miah approaches a baby in a stroller and clasps its hand with hers. The baby smiles and shuffles its feet in excitement to be noticed by such a cute girl with big bright eyes. "See that. She could have never done that before," said Tonya. For a moment Miah's success is shared between the handholding of two children.

Miah Tobin riding a horse after brachial plexus surgery. 

Miah Tobin riding a horse -- a favorite activity she couldn't do before her surgeries. 

Allison Allgier, Occupational Therapist and Clinical Coordinator for the Brachial Plexus Center, believes Miah's success is a great example of how a multidisciplinary team of medical experts and a family can work together to change the outcome for a child. "The Brachial Plexus Team feels honored to work with Miah's family and be a part of positively impacting Miah's life. The family has worked diligently to maximize the outcome of each treatment option offered by the team whether it be related to surgery or therapy," Allison said. "We are so pleased with Miah's response to treatment and look forward to seeing continued improvements in the near future. She is such a wonderful little lady."

Miah's mom feels fortunate to have discovered the Brachial Plexus Center at Cincinnati Children's when she did and realizes how different their lives would be if they had missed the window of time for surgical intervention. "I don't know how she or we would cope if she couldn't use her hand and arm at all," said Tonya. "If we hadn't found the Brachial Plexus Center, she would not have any function in her arm and hand today. Our lives would be very different right now."

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