Physical Therapy Guide to Infant Brachial Plexus Injury (Erb’s Palsy, Klumpke’s Palsy) -

Physical Therapy Guide to Infant Brachial Plexus Injury (Erb’s Palsy, Klumpke’s Palsy)

The brachial plexus is a network (group) of nerves that begin in the neck and pass under the arm. These nerves carry signals from the brain and spinal cord to the shoulder, arm, hand, and fingers. These nerve signals are required for typical movement and feeling (sensation) of the arm. When the brachial plexus nerves are injured, parts of the arm become hard to move, and sensation can be reduced. Injury to the upper part (branches) of the brachial plexus is called Erb’s (or Erb-Duchenne) palsy. Injury to only the lower part of the brachial plexus is called Klumpke’s (or Dejerine-Klumpke) palsy. In some cases, all the nerves are injured, resulting in global or total plexus palsy.

Brachial plexus injury often happens during the birth process. It occurs in 1.74 of every 1,000 infants born in the United States yearly. The nerve injury can be mild or severe and may be temporary or permanent. Infants with permanent nerve injury can develop muscle and joint tightness. Physical therapists treat infants and children with brachial plexus injury to prevent arm tightness and promote function.

Physical therapists are movement experts. They improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To find a physical therapist in your area, visit Find a PT.

What Is a Brachial Plexus Injury?

The brachial plexus is a group of nerves that runs from the neck through the shoulder to the arm. Although injury can happen at any time, most brachial plexus injuries occur during birth when an infant’s shoulder becomes wedged against the mother’s pelvis in the birth canal. This event, called shoulder dystocia, can stretch the brachial plexus, causing nerve injury. Brachial plexus injury during birth is more likely when:

The baby weighs more than 8.8 pounds.
The mother develops gestational diabetes (which contributes to the baby’s size).
The delivery requires a vacuum or forceps.
The baby is born in a breech position (meaning buttocks- or feet-first rather than head-first).

A brachial plexus injury can also happen at birth without these contributing factors.

Brachial plexus injuries range from mild or temporary to severe and permanent. Infants with more severe injuries may require surgery to help them move their arm better. There are 4 types of injury:

Neuropraxia is the most common type of injury to the nerves of the brachial plexus. When this injury occurs, one or more nerves are stretched but not torn. This injury may heal on its own in the first several weeks of life.
Neurotmesis (rupture) describes a torn nerve somewhere in the brachial plexus. Surgery may be needed to help improve muscle strength.
Avulsion is the most severe type of injury, in which the nerve is separated from the spine. Surgery will be required to restore muscle strength in nerve avulsions infants.
Neuroma results from a torn nerve that begins to heal, and scar tissue develops. This can limit arm function and prevent nerve signals from reaching the arm muscles.

Signs and Symptoms

The signs and symptoms of brachial plexus injury vary depending upon which nerves are damaged and the type of damage. The most common signs and symptoms are:

Muscle weakness in the arm. Infants and children may have trouble moving their shoulder, elbow, wrist, and/or fingers.
Problems with sensation, such as burning, stinging, or the feeling of an electric shock in the shoulder or arm.
Tightness of the muscles and joints of the arm.
Abnormal arm positioning and alignment.
Nerve and/or muscle pain, especially in older children and teens.

How Is It Diagnosed?

Brachial plexus injuries are usually obvious at birth because the infant’s arm is very weak or limp. Formal diagnosis requires a careful physical examination to determine which nerves are affected and the severity of the injury.

Some children’s hospitals offer a team approach to diagnosing and treating children with brachial plexus injuries. The specialists on the team can include:

Physicians.
Orthopedic surgeons.
Neurologists or neurosurgeons.
Physical therapists.
Occupational therapists.

The physical exam includes observation of the arm. This may be repeated several times over many months to assess muscle and nerve recovery. Special tests may be conducted as part of the exam, such as:

An electromyogram, or EMG, to assess the extent of muscle damage caused by the nerve injury.
Ultrasound to look at the position of the shoulder joint.

The physical therapist will look at arm movements and joint range of motion (movement) to see which muscles are weak or tight. The physical therapy exam is an important part of determining when and how the brachial plexus injury will be treated. Seeking treatment as early as possible from experts in brachial plexus injury can make a difference in helping a child gain use of their arm.

How Can a Physical Therapist Help?

A physical therapist is an important treatment partner for the family of any child 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 can help prevent later problems as your child grows. Your child’s physical therapist will:

Identify muscle weakness and work with your child to keep their muscles flexible and strong.
Help reduce or prevent muscle or joint tightness and poor joint alignment.
Encourage your child’s movement and function.

Physical therapy may need to continue for weeks or months, as the nerves grow again or recover from injury. Each treatment plan will be designed and adjusted to meet your child’s needs using a family-centered approach to care.

Evaluation

Your child’s physical therapist will first perform a thorough evaluation. This will include taking a detailed history of your child’s birth and developmental history. They will conduct specific tests looking at your child’s arm movement, function, and tightness. The physical therapist can test your child’s arm to determine whether some or all feeling has been lost. Physical therapists know the importance of a team approach to addressing children’s needs. They will send your child for further evaluation as needed.

Treatment

Your physical therapist will work with your child to:

Prevent or reduce arm tightness.
Maintain or improve muscle strength.
Aid in nerve repair and regrowth.

They also will work with you to adapt toys or activities to promote movement, play, and increase daily activities. Treatment will encourage your child’s participation — first in the family, and later, in the community. Your child’s treatments may include:

Education on holding, carrying, and playing with your baby. Your physical therapist will suggest ways to position your baby so their arm will be supported when they are held or carried. They also will give ideas for positioning your baby on the back or stomach for play with the arm supported. Education may also include tips on protecting the arm during dressing and bathing.

Passive and active stretching. Your physical therapist will assist you and your child in performing gentle movements. These exercises will be designed to increase joint motion and prevent or delay tightness in the arm.

Improving strength and movement. Your physical therapist will teach you and your child exercises, activities, and games to increase or maintain strength in and around the arm. They will be careful not to ask the baby or child to work too hard. Using the affected arm is encouraged during age-appropriate play activities such as finger painting, building a tower, or picking up and eating small bites of food. As your child improves and grows, your physical therapist will identify new activities to further encourage arm and hand use.

Use of modalities. Your physical therapist may use various treatment techniques (modalities) to improve muscle function and movement. Electrical stimulation gently simulates nerve signals to the muscle. Flexible tape may be placed across specific muscle areas to help guide proper movement or postures. Constraint-Induced Movement Therapy may be used on the nonaffected arm to limit its use and encourage use of the affected arm. Your physical therapist may recommend a brace to help hold the shoulder, elbow, or hand in the best alignment and decrease muscle tightness. They will work with other health care professionals to recommend the best treatments for your child.

Improving developmental skills. Your physical therapist will help your child learn to master motor skills. These include activities like reaching, sitting up with arm support, and crawling or scooting. They will provide a personalized care plan specific to your child’s needs.

Fostering participation. Your physical therapist will help you determine your child’s community involvement to promote health throughout childhood. They will continue to work with you and your child to adapt activities so your child can participate fully in family life and in society.

Treatment After Surgery

Your child’s physician may recommend nerve surgery in the first year of life to help restore as much arm movement as possible. Later surgeries for muscles or joints may be recommended if the arm is tight or movements are still difficult. Physical therapy will help your child after surgery by stretching and strengthening the arm and helping them return to activity.

Physical therapists may be provide treatment in the home or at another location, such as a hospital, community center, school, or outpatient clinic. Depending upon the severity of their injury, the child’s needs may continue and change as they age. Your physical therapist will work with other health care professionals (such as occupational therapists and physicians) to address all your child’s needs as treatment priorities change.

Can This Injury or Condition Be Prevented?

All pregnant women should seek regular prenatal care, including a test for gestational diabetes. Mothers with gestational diabetes tend to have larger babies. The larger the baby, the higher the chance that a brachial plexus injury will occur during delivery. Having a difficult delivery and shoulder dystocia with one baby increases the likelihood of a brachial plexus injury occurring with a later baby. Expectant parents should discuss prior birth experiences with their delivery health care provider to develop a strong birth plan that minimizes risk.

When a brachial plexus injury occurs, physical therapists can help prevent later problems as a child grows. Stretches are used to keep the arm from getting tight. Braces may be added to hold the joints in the best alignment and prevent joint problems. Physical therapists may be the first to notice changes in the alignment of joints. They can recommend further evaluation by a physician for treatments, such as casting or surgery.

What Kind of Physical Therapist Do I Need?

conditions or injuries. You may want to consider:

A physical therapist who is experienced in pediatrics and brachial plexus injuries. Many children’s hospitals will have special brachial plexus centers with experienced pediatric physical therapists. You may want to work with the physical therapist at the specialty center and the physical therapist in your local area, who will work with you and your child in the home, school, or community environments.
A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in pediatric physical therapy. This physical therapist has advanced knowledge, experience, and skills with brachial plexus injuries.
A team approach. Experienced pediatric physical therapists understand the importance of working with other health care professionals to maximize outcomes for children with brachial plexus injuries.

You can find physical therapists with these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you’re looking for a physical therapist (or any other health care provider):

Get recommendations from family and friends or from other health care providers.
Ask about the physical therapists’ experience helping children with brachial plexus or other nerve injuries.
Be prepared to describe your child’s symptoms and motor skills in as much detail as possible and bring any records from other health care professionals when possible.

The Academy of Pediatric Physical Therapy contributed to this consumer resource. It is for informational purposes only and is not intended to represent the position of APTA Pediatrics.

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