IF YOU READ THIS POST EARLIER I HAVE EDITED IT... I'll be checking back here, so if I am totally off track, let me know and I will try to be more helpful. I am a new grad and just started a job in peds.
I did a report on Erb's Palsy in school for OT and have attached an edited copy of my annotated reference list which has some really great websites. I believe I removed all of the information that may not be useful to you. Hopefully all of the links work for you. I know it isn't a quick and easy answer... Sorry.
In addition, I would recommend having the parents massage the limb 2-3 times daily with lotion for sensory input, and during ROM take the child through the PNF diagonals. Basically with Erb's you just want to keep ROM and strength until the nerve regenerates, unless it is an avulsion (detatched at the spinal cord)--then it will never regenerate and compensation is your only route.
Otherwise your major roles are parent education, positioning, ROM, splinting, weightbearing, tactile stim, and strengthening. I have included additional information on each below... I know you are probably already aware of most of this, but sometimes things slip by.
Parent education (lifting, dressing, positioning, etc.)
Lifting child by placing hands under arm pits may cause further injury. Prepostion limp arm on baby’s chest then place one hand under buttocks and one hand behind head to lift.
Dress affected arm first. Undress affeted arm last. This will limit any additional pushing and pulling on the arm.
For tummy play position arm in front of chest, elbow bent bringing hand close to baby’s mouth. While sleeping use pillow under armpit to sustain stretch
Do not restrain arm in flexion on top of chest for long periods
Continuously check arm for color (if pale/bluish, reposition immediately)
Offer toys/food to affected arm first to encourage awareness and use of the extremity
ROM and home program (general protocol)
Avoid bringing upper arm close to ear and pushing downward toward the chest
Move one joint at a time, 10 reps in all motions, 2-3 times a day (e.g. diaper changes)
Splinting and braces
Resting hand splint, wrist **** up splint, dynamic splints, air splints, taping
Weight bearing: different positions encourage this during play, provides proprioceptive input
Tactile stimulation: discourages neglect of extremity, sensory re-education
Strengthening: prevent/limit atrophy, work on after recovery of ROM
It is good to know the expected recovery of motor function so you know which movements to expect to come back when:
- Scapular movement (0-3 mos)
- Finger flex/ext (0-3 mos)
- Shoulder flex/abd 40-90 degrees (0-4 mos)
- Elbow flexion (0-4 mos)
- Elbow extension (0-5 mos)
- Shoulder flex/abd 90-160 degrees (4-8 mos)
- Shoulder ext rotation (8-12 mos)
- Supination (10-15 mos)
Good luck. I hope this helps! And sorry for the length of the document. I don't have a lot of time to really go through the information I am copying/pasting for you...
Annotated Reference List
Brachial plexus protocol. (n.d.). Retrieved from the Brachial Plexus Palsy Foundation Web site:
This article discusses the general types of brachial plexus nerve injury, as well as related complications that can occur following an injury. Conservative treatment techniques through passive range of motion, positioning, splinting, and air splints are covered. Also mentioned is the general timeframe for recovery as well as a referral place for evaluation of need of surgery.
De Moyano, S. S. (2003). Awareness through movement: the Feldnekrais method. Retrieved October 13, 2004, from the United Brachial Plexus Network Web site:
This article discusses a method founded by Dr. Moshe Feldenkrais. Her method is defined as “a learning system that utilizes movement and awareness of self to bring about… changes.” The basic premise is to teach the client what she can do and build trust and confidence, and then begin working on what she cannot do.
Diffendal, J. (2000, September 11). Splinting for brachial plexus surgeries [Electronic Version].
Advance for Occupational Therapy Practitioners, 32.
Erb’s palsy/brachial plexus play therapy exercises: fun activities to promote range of motion and development. (2000). Retrieved October 13, 2004, from the United Brachial Plexus Network Web site: http://188.8.131.52/resources/playtherap..
This article discusses games and activities geared toward three to six years olds. They are meant to encourage general body activities, hand coordination, and activities of daily living. Also included are general guidelines for encouraging a child to use his or her affected extremity.
Higbee, T. (2003). Baby care for infants with a brachial plexus injury. Retrieved October 13, 2004, from the United Brachial Plexus Network Web site:
This article discusses proper techniques for lifting, dressing, positioning, and doing range of motion exercises on an infant with a brachial plexus injury.
Humpl, D. (2003). A therapeutic approach to the waiter’s tip and the erb’s engram. Retrieved October 13, 2004, from the United Brachial Plexus Network Web site:
This article descrides the two most common postures seen with Erb’s Palsy. It suggests ways to help the child with each posture, including ROM, splinting, neuromuscular stimulation, threshold electrical stimulation, and surgery.
Obstetrical brachial plexus injury (OBPI). (2002). Retrieved October 13, 2004, from the United Brachial Plexus Network Web site: http://www.ubpn.org/awareness/a2002obpi...
This article has a lot of information about OBPI including etiology, diagnosis, prognosis, and sequalae deformities. It also has a nice illustration of the brachial plexus, where it originates on the spinal cord, and how it breaks off into the separate nerves of the arm.
Pape, K. (2003). Threshold electrical stimulation (TES) for brachial plexus injuries. Retrieved October 13, 2004, from the United Brachial Plexus Network Web site:
This article provides information on a conservative treatment technique for children and adults with brachial plexus injuries. The basic premise is to stimulate muscle growth so that when the nerve reinervates the muscle the muscle is not atrophied, but is instead healthy. Basic protocol and related benefits are also discussed.
Shenaq, S. M., Berzin, E., Lee, R., Laurent, J. P., Nath, R., & Nelson, M. R. (1998). Brachial plexus birth injuries and current management. Clinics in Plastic Surgery, 25(4), 527-536.
This article is very thoruough. It discusses the history of obstetrical brachial plexus injuries, incidence, risk factors, pathophysiology, physical examination, clinical presentation and classification, conservative management, and surgical management, including primary and secondary reconstruction.
Storment, M. (2002). Guidelines for therapists: treating children with brachial plexus injuries. Retrieved October 13, 2004, from the United Brachial Plexus Network Web site:
This article is written by an OT. It contains some general information on what a brachial plexus nerve injury is, as well as the different types of injury. It outlines which muscles
are expected to recover function at what ages. It also discusses when surgical treatment is recommended and general surgical techniques, as well as a more conservative treatment approach.
Stretching the limits: brachial plexus injuries and therapy. (2002). Retrieved October 13, 2004, from the United Brachial Plexus Network Web site: http://www.ubpn.org/awareness/a2002stret..
This article discusses ways to incorporate therapy into daily activities. It includes ideas to use outside, during bathtime, while dressing, with the child helping to cook, and several games. These are great ideas for a busy parent to make the best use of time spent with their child while still having fun.
Therapy services. (n.d.). Retrieved from the Brachial Plexus Palsy Center Web site: http://www.brachialplexus.wustl.edu/trea..
This article discusses the functions performed by therapists when it comes to treating brachial plexus palsy. Included aspects are home exercise programs, positioning,
splinting, and post surgical therapy.