Aside from torticollis, I think Erb’s palsy was one of the most frequently occurring diagnoses in my practice.
Statistics claim that more than 5000 babies are born each year with Erb’s palsy. It is typically a result of a difficult birth (dystocia) whereby the infant’s shoulder gets stuck during delivery. The problem can manifest with a very large baby or very small mom. The result is that the brachial plexus, which is a network of nerves, gets stretched and/or torn. The nerves of the brachial plexus stem from the neck and upper back and pass through the armpit to the arm. They are responsible for providing function to the muscles and sensation to the skin of the entire arm and upper back/shoulder.
Depending on the severity of the injury, surgery may be required. If the nerves are torn and can be repaired surgically, the doctor may decide to operate prior to the baby getting therapy, or the doctor may wait and see how much progress is made with manual treatment. Some cases resolve themselves without residual problems within a year. In my experience, all cases of Erb’s palsy require occupational therapy, and usually physical therapy as well.
When a baby does not have full function in both arms, development is delayed.
Because of the nerve injury, there is paralysis of some muscles. The baby can’t prop, push off the surface with both arms, crawl on all fours or pull to stand. I have explained in other posts how delayed physical development impacts learning. With Erb’s palsy, delayed gross and fine motor skills means that the baby isn’t playing with toys or moving around and exploring the environment. Consequently, all developmental progress is adversely affected. Even if the baby receives immediate surgery, recovery time causes development and milestone delays. Therapy will be essential to get the baby back on track.
There are many types of treatment available for this disorder. Although practitioners of certain therapy techniques swear that they can get great results, I have only seen good results when the baby receives therapeutic exercise, range of motion and performs weight bearing activities. There is a protocol known as Cranial-Sacral therapy, and its practitioners believe that it is a sound treatment for Erb’s palsy. The belief is that with the gentle placement of hands on the cranium, they can foster health via the central nervous system. According to a website “Using a soft touch generally no greater than 5 grams or about the weight of a nickel, practitioners release restrictions in the craniosacral system to improve the functioning of the central nervous system.” There is quite a bit of controversy regarding this treatment and its efficacy, so I personally can not recommend it until research can validate the claims. On a similar note, some chiropractors and osteopaths suggest that adjustments to the spine can influence nerve regeneration. It is possible that this type of treatment could be beneficial as an adjunct to more traditional occupational therapy and physical therapy, but not as a replacement.
Nerves are designed to carry messages from the brain to a muscle. When there is any dysfunction with the signal, the muscle cannot do its job properly.
Therapy needs to focus on stimulating whatever nerves are working, even minimally, and hoping that the torn or damaged nerve will heal and regain function. It is also very important to encourage movement and weight bearing so that the limb doesn’t stiffen up and “freeze” at the joint and so that the working muscles don’t lose strength and/or atrophy. Treatment can start within a few weeks of birth (3 weeks or older).
I strongly recommend that Erb’s palsy be treated by a licensed therapist. However, there are many exercises you can do at home. If you are nervous about handling your baby, then I suggest leaving the work to a professional. But if you are confident that you can do some exercises with your baby, then you should go ahead. This condition has a better chance of improving when treatment is given frequently.
Today I am going to describe a few techniques. There are a lot of activities and exercises which are helpful for Erb’s palsy, so I can’t cover all at once. I will start by offering exercises for a very young baby.
The goal of therapy is to give input to the affected limb and promote muscle function, as well as encourage growth and normal range of motion.
One very simple activity is joint compression. This can be done frequently during the day and should not cause any discomfort. I described in a previous post the exact protocol for joint compression. You can read about it in the post. The joint compression plays a different role in this case. It helps to stimulate the nerve endings. In addition, you can also take your baby’s affected hand and open it up, then place it with her palm against your palm. You might have to hold her hand flat against yours with your other hand. If you can, straighten her arm as well. If you don’t need your hand to hold her palm in place, grasp her elbow so that her arm remains straight. Once placed, give a slight, but firm push against her palm. This also gives some weight bearing into the hand and arm. Without weight bearing, the bone growth is not stimulated and the affected arm will not grow as well as the other arm. That’s why it is good to do this often. Remember, it is a slight but firm push. None of these exercises should be painful.
Another activity you can do with a young baby is passive range of motion. All you really need to do is gently move the arm through its normal motions. Move your own arm and shoulder as a guide, and then you can figure out how to move your baby’s arm and hand. If you feel any resistance, stop the movement at the point of resistance. You can flex and extend the arm at the elbow, flex and extend the hand as well as move it side to side, and you can bring the arm up straight at the shoulder and also move it gently backward.
The next exercise technique is easy to do, but a little tricky to learn. All you need is the top half of your first three fingers. Hold your fingers straight, and then sweep them quickly over the muscle belly you want to stimulate. The movement is quick and a fairly short sweep. You need to apply a small pressure to the movement. For instance, to stimulate the elbow, hold your baby’s arm in one hand. Then take the first three fingers of the other hand and place them on the forearm just below the elbow, then apply a little pressure onto the skin and quickly sweep your fingers over the muscle belly and then lift them up. Repeat this several times. The movement is a lot like trying to brush dirt off clothing while you are wearing the clothing. Try to do it to yourself with that analogy in mind. You’ll see it is quite simple. You need to apply pressure so you can get rid of the dirt. That is about the same pressure you will use for the muscle sweep. This technique can be used on all muscles of the shoulder, arm and hand.
The exercises I just described – joint compression, weight bearing, range of motion and muscle sweep/tap can be performed by anyone. They are suitable for very young infants who have not developed any gross motor skills, but are also good to use with older babies. What they will do is stimulate nerve function, give pseudo -weight bearing to the bones for growth, and help avoid contractures or “frozen” joints.
In another post, I will describe some exercises to help an older baby achieve her developmental milestones. The exercises are similar to the ones shown in my videos, but they need to be adapted because of the paralysis or weakness of the affected arm. In the meantime, these exercises are the foundation for treatment with all babies who have Erb’s palsy.