It’s a beautiful thing bringing into the world a new and perfect being; one that looks just like you. A marvelous bundle of joy. Everything is expected to be absolutely perfect; perfect eyes, nose, mouth, toes and nails but then, you notice something, your baby isn’t moving one arm like the other. It appears weak or a bit limp. This might suggest that your baby has an Obstetric Brachial Plexus Palsy/Injury (OBPP).
OBPP is defined as a form of paralysis of the arm (brachii), caused by injury to a set of nerves which make up the Brachial Plexus. The brachial plexus is a bundle of nerves that controls the upper limbs (from the shoulder to the fingers) by sending and receiving impulses. This bundle of nerves exit the spinal cord in the base of the neck with its content nerves spanning out the entire arm and hand. Injury can occur at any point across the length of the brachial plexus in its location. It could be injury to the root, trunk, or division of the brachial plexus. Hence, the brachial plexus injury or lesion sub-types and forms.
Injury to the brachial plexus can occur in several forms;
- An avulsion: Here, the nerves appear completely torn from the root and would surgically need repair.
- A rupture: This indicates a tear within a nerve/ several nerves (think of several threads loose in a rope).
- A neuropraxia: This is a less severe form of injury that occurs from obstruction of nerve(s) fibres but recovery almost occurs spontaneously. It is more of a stretch without a tear.
- A neuroma: This is when scar tissue grows around an injured nerve which has tried to heal itself, and interferes with the nerve sending signals to the muscles.
It is important to know that the severity of this condition depends on the number of nerve fibres involved and the degree of damage. Hence, either of Erb’s palsy, upper-middle brachial plexus injury, Klumpke’s paralysis, or a total obstetric brachial plexus injury could occur depending on which part of the plexus is affected.
An upper brachial plexus injury (Erb’s palsy) is the most common of the lesion sub-types and typically occurs during a cephalic delivery; when the head has presented but there is difficulty in delivering the shoulder of the baby. This is treated as a birth emergency called shoulder dystocia. The nerves most commonly affected in Erb’s palsy are the suprascapular nerve, musculocutaneous nerve and the axillary nerve.
Erb’s palsy or any other sub-type of OBPP is predominantly caused by a tearing force applied to the hand or arm during delivery especially when a baby has a birth emergency; shoulder dystocia or a breech presentation. Sometimes, when a baby weighs more than 4kg and needs a little assistance with equipment to be delivered (instrumented or assisted delivery), injury to the brachial plexus occurs.
A baby with Erb’s palsy i.e., an upper trunk injury or any other sub-type will not be able to lift the affected hand or arm like the other arm and may lose feeling or sensation in the arm as well. In the affected arm, the shoulder would appear twisted inwards (internally rotated) and close to the body (adducted), the elbow might be stretched out (extended), forearm twisted backwards (pronated), and wrist bent downwards or inwards (flexed), this position is also known as the “policeman or waiter tip” hand. All this might be noticeable when the baby cries or attempts to play with both hands.
How often do we see this condition?
Incidence of OBPP varies from country to country; in developed countries like Amsterdam 0.38-1.56 per 1,000 births, and in the US 1.51 +/- 0.02 per 1,000 births with these numbers decreasing gradually. In Nigeria, the prevalence of OBPP was reported to be at 43.8% as at 2008 and it is unknown if this percentage has increased or decreased. More than 5,000 babies are eventually born with Erb’s palsy each year.
This means that large and breech presentation babies are at risk of having an obstetric brachial plexus palsy or injury. The other possible causes of this injury could be due to excessive pulling on the shoulder during vertex presentation, excessive pressure on the raised arms during breech delivery or due to clavicle fracture unrelated to dystocia. Also, mothers who have multiple births, and diabetes are at risk of having babies with Erb’s palsy or generally, an obstetric brachial plexus palsy.
How can Erb’s palsy be treated?
As a parent, discovering that your baby has a brachial plexus injury might be disheartening but where there is a will, there is a way. A brachial plexus injury can be managed and treated by a Physiotherapist for effective function as your baby grows.
During the first 24 hours of life after delivery, a thorough assessment of the baby should be done for abnormalities; is movement spontaneous, breathing, fractures and so on. Sometimes, a brachial plexus injury presentation might be missed and later on is discovered by the parents or relatives. If there are any abnormalities especially when it comes to movement of the arms, referral for physiotherapy should be made immediately.
It is important to note that injury to the brachial plexus cannot get worse once it has occurred. But it can cause deformity and loss of function which will be evident as your baby grows.
Physiotherapy for Erb’s palsy
Physiotherapy should start soon after your baby has been diagnosed with having an Obstetric Brachial Plexus Palsy (OBPP). Physiotherapy cannot make the nerves grow back or faster as is sometimes assumed, but aims to reduce problems of stiffness occurring, because your baby cannot move their arm by themselves. Physiotherapy encourages your baby to move their arm, increases awareness of the arm and ensures your baby reaches developmental milestones at the right time.
Most times, when an OBPP occurs, not only is movement affected, sensation is also affected. When sensation is lost, neglect is inevitable. This means having impaired ability to perceive the affected arm. Sensory stimulation is important for enhancing motor performance, as well as for minimizing neglect of the affected limb.
You will be instructed and trained on how to carry out a range of motion exercises at home, which will help to keep muscles and joints flexible and ready to move, if and when nerve and muscle function improves.
A physiotherapy home programme may be designed for your baby which may include:
- How to move your baby’s arm to stop it from becoming stiff.
- How to move and handle your baby when caring for them.
- Positions to use for sleep and for play.
- Advice on activities to help with their development.
- Here are some tips for handling and properly positioning your baby with an OBPP:
- Touch and gently move your baby’s arm. Move and handle arms equally not moving one more than the other.
- Do not pull on the affected arm, nor lift under the armpits when lifting your baby.
- Ensure that the arm is well supported with the shoulder, elbow, wrist and hand in a neutral position – wrapping the baby in a blanket when moving may make handling easier in the early weeks of birth.
- Always keep your baby’s arm close to its side, or in a forward position when holding or feeding e.g., placing your baby’s hand on breast or bottle during feeding.
- Support your baby’s arm with a rolled up towel to keep that arm in a neutral position when the baby is lying on its back.
- Start with your baby’s affected arm first when dressing, and when undressing start with the unaffected arm.
- Hold your baby’s affected arm close to the body and carefully dry under the arm, and in the soft tissue folds when bathing the baby. Gently massage the arm regularly during the day.
- Bring your baby’s hands together, and to their face, drawing visual attention to the affected limb.
- Encourage your baby to bear weight on the affected arm as this provides proprioceptive input and can also contribute to skeletal growth, when the baby has developed sufficient head control.
Physiotherapists understand how important motor and sensory function is for the development of your baby regardless of an OBPP. Hence,the commitment towards proper management and treatment. Every child deserves a chance to play with both hands.
Development of a protocol for the management of Obstetric Erb’s palsy (2015). Pragyan Singh and Kolamala K. The Indian Journal of Occupational Therapy: Vol. 47: No. 1 (January 2015 – April 2015).
Obstetric Brachial Plexus Palsy: A Guide to Management (2012). Association of Paediatric Chartered Physiotherapist. Available at www.apcp.org.uk.
Seattle children’s hospital/Research/Foundation. Brachial Plexus Palsy: A Therapy Guide for Your Baby. Patient and Family Education. Available at www.seattlechildrens.org
Ogwumike O.O, Adeniyi AF, Badaru U, Onimisi JO (2014). Profile of children born with new-born brachial plexus palsy managed in a tertiary hospital in Ibadan, Nigeria. Nigerian Journal of Physiological Science 29;001-005.