Physiotherapy for Erb’s Palsy
Erb’s palsy or Erb-Duchennepalsy is a paralysis of the arm caused by injury to the Brachial Plexus, specifically the upper brachial plexus. It is the most common birth related neuropraxia (about 48%).
Mechanism of injury
The most common cause of Erb’s palsy is dystocia, an abnormal or difficult childbirth or labor. For example, it can occur if the infant’s head and neck are pulled toward one side, at the same time when the shoulders pass through the birth canal. The condition can also be caused by excessive force applied on the shoulders during a vertex presentation (head first delivery), or by pressure on the raised arms during a breech (feet first) delivery.
A similar injury may be observed at any age following trauma to the head and shoulder, which cause the nerves of the plexus to violently stretch, with the upper trunk of the plexus sustaining the greatest injury. Injury may also occur as a result of direct violence, including gunshot wounds and traction on the arm, or attempting to diminish shoulder joint dislocation. The level of damage to the constituent nerves is related to the amount of paralysis.
Signs and symptoms
The signs and symptoms of brachial plexus injury vary, depending upon which nerves are damaged and the extent of the damage. Major damage may result in a limp or paralyzed arm. The arm muscles are weak and lack feeling or sensation.
In Erb’s Palsy, the signs may be a stiff arm that is rotated inward with the wrist fully bent and fingers extended. This position is often called the “waiter’s tip” because it resembles a food server holding the hand discreetly for a tip.
How is it diagnosed?
Brachial plexus injuries are often apparent at birth because the infant’s arm is either limped or unusually stiff. Diagnosis of the injury requires a careful neurological examination by a specialist to determine which nerves have been affected, and the severity of the injury. Usually, the examination will include physical observation of the arm as well as some special tests, such as an electromyogram (EMG) that reveals the extent of muscle damage caused by the nerve injury. A nerve conduction study (NCS) may be used to determine how far signals are transmitted along the nerves. Other scans may be required to assess the damage of the nerves.
How can a physical therapist help?
A physical therapist is an important family treatment partner for any child diagnosed with a brachial plexus injury. Physical therapy should begin as soon as possible after diagnosis or surgery, and before joint or muscle tightness develops. Physical therapists will:
- Identify muscle weakness and work with each child to keep muscles flexible and strong
- Help reduce or prevent muscle or joint contractures (tightening) and deformities
- Encourage movement and function
Even when surgery is not required, therapy may need to continue for weeks and months as the nerves grow again or recover from damage. Children with Erb’s Palsy will usually recover when they turn 6 months old, but other palsies may require a longer treatment. Each treatment plan is designed to meet the child’s needs using a family-centered approach to care.
Evaluation
Your child’s physical therapist will perform an evaluation that includes a detailed birth and developmental history. Your child’s physical therapist will perform specific tests to determine arm function, such as getting the child to bring the hands together, grasp a toy, or use the arm for support or for crawling. The physical therapist will test arm sensation to determine whether some or all feeling has been lost, and educate the family about protecting the child from injuries when the child may not be able to feel pain. Physical therapists know the importance of addressing the child’s needs with a team approach, review all health care assessments, and send the child for further evaluation, if needed.
Treatment
Physical therapists work with children with brachial plexus injury to prevent or reduce joint contractures, maintain or improve muscle strength, adapt toys or activities to promote movement and play, and increase daily activities to encourage participation—first in the family, and later, in the community. Treatments may include:
- Education on holding, carrying, and playing with the baby: Your physical therapist will make suggestions for positioning, so that your baby’s arm will not be left hanging when the baby is being held or carried. Your physical therapist will provide ideas for positioning the baby on the back or stomach for play without injury to the arm.
- Prevention of injury: Your physical therapist will explain the possible injuries that could occur without the baby crying, since the baby cannot perceive pain if sensation is limited in the arm.
- Passive and active stretching: Your physical therapist will assist you and your child in performing gentle stretches to increase joint flexibility (range of motion), and prevent or delay contractures (tightening) in the arm.
- Improving strength: Your physical therapist will teach you and your child exercises and play activities to maintain or increase arm strength. Your physical therapist will identify games and fun tasks that promote strength without asking the baby to work too hard. As your child improves and grows, your physical therapist will identify new games and activities that will continue to strengthen the arm and hand.
- Use of modalities: Your physical therapist might use a variety of intervention techniques (modalities) to improve muscle function and movement. Electrical stimulation can be applied to gently simulate the nerve signal to the muscle and keep the muscle tissue functional. Flexible tape can be applied over specific muscle areas to ease muscle contraction. Constraint-induced movement therapy (CIMT) may be applied to the non affected arm to encourage use of the affected arm. Repetitive training of the affected arm is encouraged, using age-appropriate tasks, such as finger painting, building a tower, or picking up and eating small bites of food. Your physical therapist will collaborate with other health professionals to recommend the best treatment techniques for your child.
- Improving developmental skills: Your physical therapist will help your child learn to master motor skills, like putting the child’s weight on the injured arm, sitting up with arm support, and crawling. Your physical therapist will provide an individualized plan of care that is appropriate based on your child’s needs.
- Fostering physical fitness: Your physical therapist will help you determine the exercises, diet, and community involvement that will promote good health throughout childhood. Your physical therapist will continue to work with you and your child to determine any adaptations that may be needed, so that your child can participate fully in family life and in society.
Therapy may be provided in the home or at another location, such as a hospital, community center, school, or a physical therapy outpatient clinic. Depending upon the severity of the brachial plexus injury, the child’s needs may continue and vary greatly as the child ages. Your physical therapist will work with other healthcare professionals, eg, occupational therapists and physicians, to address all your child’s needs as treatment priorities shift.
