This document provides information about brachial plexus injuries (BPI) that occur at birth. BPI results from damage to the nerves in the brachial plexus, which can occur during difficult childbirth situations like shoulder dystocia. The document describes classifying BPI by anatomical location and degree of nerve damage. Occupational therapy focuses on maintaining range of motion and promoting movement patterns to prevent musculoskeletal issues. Pediatric constraint-induced movement therapy is discussed as a treatment approach using constraint of the unimpaired arm with intensive practice of the impaired arm. Recovery generally takes 5-6 years with ongoing therapy.

1. Stephanie Lancaster, MS, OTR/L, ATP, CAPS

2. Follow this link to access the pretest for this module.
https://goo.gl/forms/2BvGdGZBqsxdRCqE3
Note: While you should always try your best, your score on the
pretest will not be recorded as a grade. The pretest will give you an
idea of what kinds of things to pay attention to as you go through the
module.

3. Follow this link to access a 20 minute video that reviews the anatomy of the
brachial plexus: Review of the brachial plexus – see
https://www.youtube.com/watch?v=RvbmbDdtzJI&sns=em

4. BPI BPP
Weakness related to damage to the nerves in the brachial plexus
Incidence: 0.4 – 4 per 1,000 births per year
(Pham, Kratz, Jelin, & Gelfand, 2011)

6.  Absence of movement
in all or part of
affected UE
 Weakness or lack of
muscle control in
affected UE
 Loss of sensation in
affected UE

8.  Shoulder adducted and
internally rotated, arm
adducted.
 Elbow extended and
forearm pronated.
 Wrist and fingers flexed
(“waiter’s tip”)
 Possible eye, neck,
and/or diaphragm
involvement
 Flaccid paralysis in
more severe (complete)
injuries
Source: http://stevensbrachialplexusinjury.blogspot.com

10. BPI is most commonly associated with shoulder dystocia, which occurs
when an infant’s anterior shoulder becomes trapped behind the mother’s
symphysis pubis (#5 in the picture on the right above) during birth.

11. By Anatomical
Location
By Degree of
Nerve Damage

12. By Anatomical
Location
GROUP I: Upper-root injury  Erb-Duchenne Palsy or Erb’s Palsy
GROUP II: Lower-root injury  Klumpke’s Palsy
GROUP III: Complete injury from C5-T1  Erb-Klumpke Palsy

13. By Degree of
Nerve Damage
Neuropraxia
Neuroma
Neurotmesis
Avulsion

14.  The site and type of
BPI determines the
prognosis.
 With neuroma and
neuropraxia injuries,
the potential varies
(Hale, Bae, & Waters,
2010).

15. 10%

16. Weakness
Paralysis
Disuse of
affected
UE

18.  Occupational therapy
assessment includes -
• Observation of
engagement in
occupations (e.g.,
feeding, bathing,
dressing)
• Manual muscle testing if
able and AROM

19. For infants/young
children:
 Positioning
 Facilitation of play and
motor skills
 PROM exercises
 Parent education,
 Splinting (some cases)
 Frequently reporting to
referring physician

21. http://themotorstory.org

22. In general, how long does it take for recovery (as much as is
possible) to occur in an injury that happens at birth?
• Generally 5-6 years in a child
• During that time, the overall
goal of OT is to maintain full
PROM of all joints (Ramey,
Coker-Bolt, & DeLuca)
• Promotion of positioning and
movement patterns is crucial in
this period as well to prevent
permanent musculoskeletal
abnormalities.

23. P-CIMT is “a concentrated, multicomponent form of pediatric therapy
focused on promoting increased voluntary control and functional
competence of the hemiparetic UE” (Ramey, Coker-Bolt & DeLuca, p. 20).

24. Distinguishing Characteristics:
 Some form of constraint to the un- or less
impaired UE
 Systematic efforts to shape new skills in the
affected (non-constrained) UE with repetitive
practice of these skills
 Relatively high levels (dosage or intensity) of
therapy for the affected UE
Ramey, Coker-Bolt & DeLuca, 2011

25. Some of the most prominent researchers in this area currently
recommend the lowest threshold be at least 3 sessions per week
with a minimum session time of 1.5 hours over a course of 2
weeks.
Ramey, Coker-Bolt & DeLuca, 2011
Call for decreased
intensity

26. https://www.youtube.com/watch?v=MeztBo3YnhU

27. Use the following link to access and complete a post-test to show that you
have completed this module: https://goo.gl/forms/FY33yGFzxTVL2U093
Note: While you should always try your best, your score on the post-test will
not be recorded as a grade.
Suggested Resource for Review:
OT Miri YouTube videos - https://youtu.be/F9vCI-llsIs

28. Hale, H. B., Bae, D. S., & Waters, P. M. (2010). Current concepts in the
management of brachial plexus birth injury. Journal of Hand
Surgery, 35A, 322-331.
Pham, C. B., Kratz, J. R., Jelin, A.C., & Gelfand, A. A. (2011, Aug. 16).
Child neurology: Brachial plexus birth injury: What every
neurologist needs to know. Neurology, 77(7), 695-697.
Price, A., Tidwell, M., & Grossman, J. A. I. (2000). Improving shoulder
and elbow function in children with Erb’s Palsy. Seminars in
Pediatric Neurology, 7(1), 44—51.
Ramey, S. L., Coker-Bolt, P., & DeLuca, S. C. (2013). Handbook of
Pediatric Constraint-Induced Movement Therapy (CIMT).
Bethesda, MD: AOTA Press, Inc.
Storment, M. (n.d.). Guidelines for therapists: Treating children with
brachial plexus injuries. Retrieved from
http://www.ubpn.org/resources/medical/pros/therapists/122-
therapyguidelins