Erb's Palsy (Brachial Plexus Birth Injury): Rehab

Pathophysiology of Erb's Palsy

Erb's palsy (also known as Erb-Duchenne paralysis) is a traction injury to the brachial plexus—a network of nerves that conducts signals from the spinal cord to the shoulder, arm, and hand. The injury specifically damages the upper trunk of the brachial plexus, formed by the C5 and C6 cervical nerve roots.

This injury typically occurs during childbirth when the baby's head is pulled to one side while the shoulder is held back (shoulder dystocia). This stretches or tears the upper nerves, resulting in sensory loss and motor weakness in the shoulder and arm muscles (primarily the deltoid, biceps, brachialis, and supinator).

Typical Clinical Presentation

The classic physical sign of Erb's palsy is the "waiter's tip" posture:

• Shoulder: Held close to the body (adducted) and turned inward (internally rotated).
• Elbow: Positioned straight (extended) due to loss of bicep function.
• Forearm: Turned palm-backward (pronated).
• Wrist & Fingers: Bent downward (flexed).

In addition, the infant may have a reduced or absent Moro reflex (startle reflex) on the affected side, and the arm may feel limp during handling.

Pediatric Physiotherapy Rehabilitation Protocol

Physiotherapy should begin after a brief rest period (typically 7-14 days after birth) to allow any local swelling or bone fractures (such as a clavicle fracture) to heal.

1. Passive Range of Motion (PROM) Exercises

To prevent joint contractures (especially in the shoulder and elbow), parents are taught to perform gentle stretching exercises during diaper changes, 3-4 times daily:

• Shoulder Abduction & Flexion: Gently raising the baby's arm up and out, supporting the shoulder blade.
• Shoulder External Rotation: Keeping the elbow bent at 90 degrees and gently rotating the forearm outward.
• Forearm Supination: Gently turning the baby's palm to face upward.

2. Sensory Stimulation

Nerve injury can cause numbness or abnormal sensations. Sensory play helps stimulate neural pathways:

• Stroking the affected arm with varied textures (cotton balls, soft brushes, corduroy).
• Massaging the arm and hand using baby-safe lotion.
• Encouraging the baby to touch their own face or bring both hands to their mouth.

3. Active Movement Promotion (Facilitated Play)

• Bimanual Play: Placing toys in the center of the baby's chest to encourage them to use both hands to reach.
• Tummy Time: Encouraging weight-bearing through the forearms, which stimulates shoulder muscles and improves joint stability.
• Side-Lying Play: Positioning the baby on their unaffected side, which makes it easier for them to lift and move their weak arm against gravity.

If you have concerns about your infant's arm movement, seek an assessment from a pediatric specialist. For more details, explore our guides on pediatric rehabilitation services or read about developmental milestone delays.

References

• Al-Qattan MM et al. Obstetrical brachial plexus injury. Journal of Hand Surgery. 2003.
• Bialocerkowski A et al. Physiotherapy management of obstetric brachial plexus palsy: a systematic review. Pediatric Physical Therapy. 2005.
• Pondaag W et al. Natural history of obstetric brachial plexus palsy: a systematic review. Developmental Medicine & Child Neurology. 2004.