Erb's palsy is a paralysis of the arm caused by injury to the C5-C6 nerve roots of the brachial plexus during birth, often due to shoulder dystocia. It results in weakness of shoulder and arm muscles. Treatment may involve physical therapy to improve range of motion and strength or surgery to repair damaged nerves. Physiotherapy management involves gentle range of motion exercises initially, followed by more active movement and strengthening exercises as the child develops. The goal is to regain function and prevent deformities while supporting age-appropriate development. Recovery can take 6 months to a year with outcomes ranging from full recovery to permanent impairment depending on the severity of injury.

1. ERB’S PALSY
Prepared By – Tsion Gudeta (PT)
1

2. Outline
• Definition
• Epidemiology
• Etiology
• Pathophysiology
• Complications
• Assessment
• Medical management
• Physiotherapy Management
• Discharge protocol/ Outcome measures
• Reference 2

3. Definition
• Erb's palsy is a paralysis of the arm caused by injury to the upper group of the arm's main nerves,
specifically the C5–C6 nerves roots.
• Erb's palsy is a form of obstetric brachial plexus palsy.
• The injury can either stretch, rupture or avulse the roots of the plexus from the spinal cord
• Depending on the nature of the damage, the paralysis can either resolve on its own over a period
of months, require rehabilitative therapy, or surgery.
3

4. Clinical Appearance
• Classical sign of Erb’s palsy is called Waiter’s Tip deformity
4

5. Epidemiology
• It occurs at 1-3 per 1000 births
• Statistics claim that more than 5000 babies are born each year with Erb's palsy
• There is a greater prevalence of right arm Erb's palsy over the left side, with a rate of 1.3:1 to 7:1, with
only 3% affecting both arms.
• Permanent impairment occurs at a rate of 3-25% of patients with Erb's palsy.
• Females seem to be slightly more affected by Erb's palsy in brachial plexus birth palsies than males, while
this proportion greatly inverts in adulthood, with more accidents occurring in males.
5

6. Etiology
• Erb’s palsy typically occurs when an infant’s neck is stretched to the side combined with a downward force on
the shoulder during a difficult delivery usually associated with shoulder dystocia.
• Occasionally, Erb’s palsy occurs when a baby is larger than usual – making delivery difficult. This can occur
due to poorly managed maternal diabetes or gestational diabetes.
• Sometimes, pulling on the infant's shoulder during delivery or excessive pressure on the baby's raised arm during
a breech delivery can cause brachial plexus injury.
• maternal obesity, maternal diabetes, or vacuum and forceps delivery. Erb’s palsy may also occur following a
cesarean section
6

7. 7

8. Pathophysiology
• This usually happens during a delivery complicated by shoulder dystocia.
• Excessive traction to the baby's head in opposite direction from the shoulder produces stretching to the nerve fibers
that can lead to a simple temporal disruption or compression, to a complete tear of the entire plexus.
• The superior trunk of the brachial plexus has a motor and sensory fibers. Palsy of C5 and C6 roots affects the
movement of deltoid, biceps, brachialis, infraspinatus, supraspinatus, and serratus anterior muscles, as well as the
sensation of the skin of the shoulder, anterolateral forearm, index and thumb fingers.
• Consequently, the child is unable to abduct or externally rotate the shoulder, as well as supinate the forearm
because of weakness.
8

9. Complications
• Pain and movement difficulties can be a short term complications.
• Many long term complications of Erb's palsy due to impaired innervation are:
1) decreased strength
2) abnormal movement and function of joints
3) muscular atrophy
4) impaired bone growth
5) osteoarthritis
9

10. Assessment
• Assessment should start on the first contact and continue throughout the follow up of the child .
• Mother or care giver should attain all sessions from the time of initial contact to the period of discharge to learn
how to handle and give care for the child at home from the physiotherapist.
10

11. Subjective assessment
• Demographic Data
• Duration of labor or if there was prolonged second stage labour.
• Type of presentation & delivery: breech, vertex presentation , caesarean section.
• Use of assistive techniques to aid delivery ( forceps, Vacuum Extractor delivery).
• Weight of the child during birth or Fetal microsomal
• Previous deliveries resulting in brachial plexus birth palsy
• Maternal history of diabetes mellitus or maternal obesity
• What activities can and can’t perform by the child with the affected upper limb.
11

12. PHYSICAL EXAMINATION
• During assessment the child should be completely undressed to allow free movement of the upper limb in warm
room.
• Things to assess:
• Observation: the child’s activity in supine, prone, sitting and being carried by Caregiver.
• observing spontaneous activities in the fingers, wrist, elbow and shoulders as child plays
• Presence or absence of a Horner's sign
• Resting posture of the affected limb—flaccid, “waiter's tip”
• Evidence of trophicity
12

13. • Palpation of both supraclavicular fossae (a large neuroma can frequently be appreciated)
• Physical examination- most often shows decreased or absent movement of the affected arm & Retained ability
to grasp.
• Neurologic examination- Sensation, reflexes- moro reflex is absent on the affected arm
• Comprehensive examination of the entire body: identify any other injuries that might have occurred during
delivery such As torticollis, fracture and neurological deficits, which could affect prognosis.
13

14. Management
• The management of Erb's palsy depends upon its severity, with some cases requiring surgical intervention while
others can be managed by physiotherapy alone.
Surgical
• If a child with Erb’s palsy shows no signs of healing by about 6 months of age, or if the healing process is too slow
or inadequate, surgery may be an option to restore movement and feeling.
• The three most common treatments for Erb's Palsy are: Nerve transplants (usually from the opposite leg), Sub
Scapularis releases and Latissimus Dorsi Tendon Transfers.
14

15. Physiotherapy treatment
• Stage 1. first 2 weeks
• Careful handling is required and extremes of motion are to be avoided for the first 1 to 2 weeks to allow for the
initial inflammatory response to the injury to calm
• Goal: Educate the care givers on how to handle and position the child
• Hand Position: The parent should hold the arm in supination and external rotation, and place small pillow
or folded towel under arm pit alongside the arm when the child is resting or sleeping.
• Dressing: For dressing, start with the affected arm and for undressing start with the unaffected arm
• Avoid picking a child up by the arm. or from under the armpit. This can compress or stretch the brachial
plexus and cause further injury
15

16. Stage 2. from week 2 – 4months
• Goals: To improve ROM, Sensation and Muscles strength.
• Gentle and slow PROM exercise should be used to increase joints flexibility, but it should be within the
available ROM (10 repetitions for each movement.)
• Stabilize the scapula during PROM of the shoulder.
• Tactile sensory stimulation, using different textured materials, for example brushing techniques to increase the
sensory awareness of the affected arm.
• Joint compression: through weight bearing exercises to increase the proprioceptive input and isometric muscle
cocontracture
• To gain milestones and age appropriate skills (head control, righting reactions).
• Continue same instruction given during the first stage.
16

17. Stage 3. from 4 month- 6 months
• Goals:
• Using Constraint-Induced Movement Therapy (CIMT)
• To improve or maintain ROM, Sensation and Muscles Strength.
• To gain milestones and age appropriate skills (rolling, protective reactions, reaching).
• To prevent joint contracture and deformities.
• Continue the same program of above stages.
17

18. Stage 4.from 6 month to 1 year
• Goals:
• To improve or maintain ROM, Sensation and Muscles Strength
• To gain milestones and age appropriate skills (sitting, crawling, standing, walking)
• To prevent joint contracture and deformities.
• Continue the same program for above stages.
• As the child grows, strength and coordination are increased by active use of the affected arm using a
variety of developmentally appropriate activities and specific functional skills.
18

19. • When the child is old enough, have them do exercises themself to
increase strength and ROM
19

20. In the form of play
20

21. Outcome measure
• The Toronto Test Score quantifies upper-extremity function and can be used to predict recovery
in infants with brachial plexus birth palsy. It is designed to predict outcome, and to differentiate
between good and poor recovery groups. If the score is less than 3.5 at 3 months of age, poor
recovery is expected.
21

22. Discharge Protocol
• If the baby's arm fully recovers the baby will be discharged.
• If there is incomplete recovery the physiotherapist will continue to monitor and advise and may refer to other
treatment.
22

23. References
• Physiopedia
• Grigoryan, A., Lytras, D., Paris Iakovidis, A., Kottaras, K.G.P. and Chasapis, G.,
2021.
• Disabled Village Children pdf By David Werner
• Rehabilitation of Neonatal Brachial Plexus Palsy Fátima Frade 1, Juan Gómez
Published on 5 July 2019
23

24. Thank You
24