Physical Therapist's Guide to
Infant Brachial Plexus Injury (Erb’s Palsy, Klumpke’s Palsy)
The brachial plexus is a network (bundle) of nerves in the shoulder and under the arm. The network is composed of the nerves that carry signals from the spinal cord to the shoulder, arm, hand, and fingers. These signals transmit information through the brain, the spinal cord, and the arm and hand, and are required for typical movement and feeling (sensation). If nerves in the upper part of the brachial plexus bundle are damaged, the injury is called Erb’s (or Erb-Duchenne) palsy. If the nerves in the lower part of the brachial plexus are damaged, the injury is called Klumpke’s (or Dejerine-Klumpke) palsy. In some instances, all the nerves may be damaged, resulting in global palsy.
Injuries to the brachial plexus result in movement and sensation difficulties in the arm, which may be mild or severe, and temporary or prolonged. Brachial plexus injury occurs in approximately 1.5 of every 1,000 infants born; the rate of injury is lower in smaller infants (under 6 pounds) and increases as the size of the infant increases, especially in babies who weigh 9 pounds or more. Physical therapists provide specific treatments to help infants with brachial plexus injury heal and develop age-appropriate muscle strength and movement skills.
What is a Brachial Plexus Injury?
The brachial plexus is a bundle of nerves that runs from the neck through the shoulder to the arm. Although injury can happen at any time, most brachial plexus injuries occur during birth when an infant's shoulder becomes wedged in the birth canal. This event, called shoulder dystocia, can stretch the brachial plexus, damaging the nerves. The delivery becomes an emergency situation and additional maneuvers are required to deliver the infant. Injury also may occur without shoulder dystocia if the labor is long, the infant is large, the mother develops gestational diabetes, the delivery requires external assistance (eg, use of forceps), or if a breech birth (ie, buttocks or feet first rather than head first) occurs. In some instances, a brachial plexus injury can happen at birth without any of these contributing factors.
Brachial plexus palsies result from 4 types of nerve injuries:
- Neuropraxia, the most common type of injury to the nerves of the brachial plexus, occurs when 1 or more of the nerves are stretched and damaged, but not torn. This injury may heal spontaneously.
- Neuroma results from a torn nerve that begins to heal, but scar tissue develops. The scar tissue puts pressure on the injured nerve and prevents signals from being transmitted between nerves and muscles. Neuroma injuries require treatment to heal.
- Rupture describes a torn nerve when the tear is not at the site where the nerve attaches to the spine. Surgery will be required, and the muscles may continue to weaken if physical therapy treatment does not occur following surgery.
- Avulsion is the most severe type of injury in which the nerve is torn from the spine. The size and growth of the arm or hand may be affected, and damage may be present for life.
Signs and Symptoms
The signs and symptoms of brachial plexus injury vary, depending upon which nerves are damaged and the extent of the damage. Major damage may result in a limp or paralyzed arm. The arm muscles are weak and parts of the arm lack feeling or sensation.
In Erb's palsy, the signs may be a stiff arm that is rotated inward with the wrist fully bent and fingers extended. This position is often called the "waiter's tip" because it resembles a food server holding the hand discreetly for a tip.
If other nerves are damaged, as in global palsy, the posture of the arm will be different. Sometimes the fingers and hand can move even when the arm has limited movement. Whether or not pain is present, or the amount of pain that is experienced, are dependent upon the extent of the nerve damage.
How Is It Diagnosed?
Brachial plexus injuries are often apparent at birth because the infant's arm is limp or unusually stiff. Diagnosis of the injury requires a careful physical examination by a specialist to determine which nerves have been affected, and the severity of the injury. The examination will include physical observation of the arm, and may be repeated several times over many months to assess muscle and nerve recovery. Sometimes special tests may be completed as part of the examination, such as an electromyogram (EMG) that reveals the extent of muscle damage caused by the nerve injury. A nerve conduction study (NCS) may be used to determine how far signals are transmitted along the nerves. Other scans may be recommended to assess the damage to the nerves, or to look at the shoulder-joint position, which may be affected by muscle weakness.
Some children's hospitals offer a team approach in diagnosing and treating children with brachial plexus injuries. The specialists on the team might include physicians, orthopedic surgeons, and physical therapists. Surgery may be necessary if the nerve damage is too extensive for recovery with therapy alone. Physical therapy will likely be a part of the treatment plan, whether or not the child has surgery. Sensory reeducation may be included if the brain forgets how the arm and hand should function during the time the nerve is regrowing or healing. Seeking treatment as early as possible, and seeking care by experts in brachial plexus injury can make a big difference in helping a child gain use of the arm.
How Can a Physical Therapist Help?
A physical therapist is an important family treatment partner for any child diagnosed with a brachial plexus injury. Physical therapy should begin as soon as possible after diagnosis or surgery, and before joint or muscle tightness has developed. Physical therapists will:
- Identify muscle weakness and work with each child to keep muscles flexible and strong
- Help reduce or prevent muscle or joint contractures (tightening) and deformities
- Encourage movement and function
Even when surgery is not required, physical therapy may need to continue for weeks and months, as the nerves grow again or recover from damage. Each treatment plan is designed to meet the child's needs using a family-centered approach to care.
Your child's physical therapist will first perform a thorough evaluation that includes a detailed birth and developmental history. The therapist will perform specific tests to determine your child’s arm function, such as getting the child to bring the hands together, grasp a toy, or use the arm for support or for crawling. The physical therapist will test arm sensation to determine whether some or all feeling has been lost, and educate the family about protecting the child from injuries when the child may not be able to feel pain. Physical therapists know the importance of addressing the child’s needs with a team approach; they will review all health care assessments, and send the child for further evaluation as needed.
Physical therapists work with children with brachial plexus injury to prevent or reduce joint contractures, maintain or improve muscle strength, adapt toys or activities to promote movement and play, and increase daily activities to encourage participation—first in the family, and later, in the community. Treatments may include:
Education on holding, carrying, and playing with your baby. Your physical therapist will make suggestions for positioning, so that your baby's arm will not be left hanging when the baby is being held or carried. Your physical therapist will provide ideas for positioning the baby on the back or stomach for play without injury to the arm.
Prevention of injury. Your physical therapist will explain the possible injuries that could occur without the baby crying, since the baby cannot perceive pain if sensation is limited in the arm.
Passive and active stretching. Your physical therapist will assist you and your child in performing gentle stretches to increase joint flexibility (range of motion), and prevent or delay contractures (tightening) in the arm.
Improving strength. Your physical therapist will teach you and your child exercises and play activities to maintain or increase arm strength. Your therapist will identify games and fun tasks that promote strength without asking the baby to work too hard. As your child improves and grows, your physical therapist will identify new games and activities that will continue to strengthen the arm and hand.
Use of modalities. Your physical therapist might use a variety of intervention techniques (modalities) to improve muscle function and movement. Electrical stimulation is sometimes applied to gently simulate the nerve signal to the muscle. Flexible tape can be applied over specific muscle areas to help guide proper muscle movement, or promote relaxation. Constraint-induced movement therapy (CIMT) may be applied to the nonaffected arm to gently limit its use and encourage use of the affected arm. A fun physical therapy session in the pool may help with stretching and strengthening. Repetitive training of the affected arm is encouraged, using age-appropriate tasks, such as finger painting, building a tower, or picking up and eating small bites of food. Your physical therapist will collaborate with other health care professionals to recommend the best treatment techniques for your child.
Improving developmental skills. Your physical therapist will help your child learn to master motor skills, like putting the child’s weight on the injured arm, sitting up with arm support, and crawling. Your physical therapist will provide an individualized plan of care that is appropriate based on your child’s specific needs.
Fostering physical fitness. Your physical therapist will help you determine the exercises, diet, and community involvement that will promote good health throughout childhood. Your physical therapist will continue to work with you and your child to determine any adaptations that may be needed, so that your child can participate fully in family life and in society.
Physical therapy may be provided in the home or at another location, such as a hospital, community center, school, or a physical therapy outpatient clinic. Depending upon the severity of the brachial plexus injury, the child's needs may continue and vary greatly as the child ages. Your physical therapist will work with other health care professionals (eg, occupational therapists and physicians) to address all your child's needs, as treatment priorities shift.
Can this Injury or Condition be Prevented?
All pregnant women should seek good prenatal care, including a test for gestational diabetes. Mothers with gestational diabetes tend to have larger babies. The larger the baby, the higher the chance of brachial plexus injury during delivery. Attentive care during labor and delivery is extremely important. Specific positioning of the mother during the delivery may improve the infant's movements through the birth process; the delivery health care provider may be able to suggest the most helpful positions. The use of equipment to assist in delivery also has been associated with brachial plexus injury. Some parent advocate groups recommend that families consider the birth environment if the mother has known risk factors associated with brachial plexus injury. A birthing facility with the ability to quickly adapt to complications may prevent or diminish shoulder dystocia (injury that occurs when the baby’s shoulder becomes wedged in the birth canal). Having a difficult delivery and shoulder dystocia with one baby increases the likelihood of a brachial plexus injury with a subsequent baby. Expectant parents should discuss prior birth experiences with their delivery health care provider to develop a strong birth plan that minimizes risk.
Real Life Experiences
Ava was born at full-term following a difficult and long delivery. She weighed more than 9 pounds and had some difficulty breathing just after birth. Ava recovered quickly, but was placed in the neonatal intensive care unit (NICU) for observation. When her parents visited her in the nursery, they expressed concern that she was not moving her right arm. The neonatologist physician explained that the team was monitoring the baby; the nerves in the shoulder and arm may have been stretched during the lengthy delivery. Ava was still not moving her arm when the family was ready to leave the hospital several days later. The physician explained that the nerves in the shoulder and arm had been injured during the lengthy delivery, and referred the family to a nearby children's hospital.
Following a thorough evaluation by a health care team at the children’s hospital, Ava was found to have Erb's palsy (the nerves in the upper part of the brachial plexus bundle were damaged in her right arm), with a likely neuroma (a partially-healed nerve tear with scar tissue). Ava and her family were referred right away to a physical therapist in their neighborhood.
Ava’s physical therapist reviewed her history and examined her. He performed stretching and strengthening activities during her physical therapy sessions, and developed an individual home-exercise program for her and her parents to follow, designed to maintain strength and movement in the muscles of Ava’s arm. He taught her parents how to gently perform the exercises, and encouraged the family to do them every day.
Ava’s physical therapist described normal developmental activities with her family, and helped them understand what arm and hand movements a young baby should be performing. He scheduled Ava for intensive physical therapy twice per week.
Ava’s health care team will be watching her recovery closely over many months to determine whether or not surgery will be necessary to help her arm heal and gain function. In the coming months, Ava's physical therapist will help her and her family:
- Gain independent use of her shoulder, arm, and hand.
- Engage in activities that maintain her arm strength and minimize muscle weakening.
- Learn about the characteristics of brachial plexus injury at different ages and the appropriate treatments for Ava as she grows.
- Promote healthy and fun activities.
- Know and use resources, such as the United Brachial Plexus Network.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is experienced in pediatrics and brachial plexus injuries. Many hospitals dedicated to the care of children will have special brachial plexus centers with experienced pediatric physical therapists. You may want to work with the physical therapist at the specialty center and the physical therapist in your local area, who will work with you and your child in the home, school, or community environments.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in pediatric physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to brachial plexus injuries.
- A team approach. Experienced pediatric physical therapists understand the importance of working with other health care professionals to maximize outcomes for children with brachial plexus injuries.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping children with brachial plexus injury or other nerve injuries.
- During your first visit with the physical therapist, be prepared to describe your child's symptoms and motor skills in as much detail as possible, and bring any records from other health professionals when possible.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.
The following articles and resources provide some of the best scientific evidence related to the treatment of brachial plexus injury. The sites and articles listed here are linked either to a professional organization or to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
National Institute of Neurological Disorders and Stroke. Information page on brachial palsy birth injuries. National Institute of Health website. Updated March 27, 3019. Accessed April 30, 2019.
United Brachial Plexus Network. Accessed April 30, 2019.
March of Dimes. Shoulder dystocia information page. March of Dimes website. Accessed April 30, 2019.
Smith BW, Daunter AK, Yang LJ, Wilson TJ. An update on the management of neonatal brachial plexus palsy-replacing old paradigms: a review. JAMA Pediatr. 2018;172(6):585–591. Article Summary on PubMed.
Abzug JM, Kozin SH. Evaluation and management of brachial plexus birth palsy. Orthop Clin North Am. 2014;45(2):225–232.Article Summary on PubMed.
Hale HB, Bae DS, Waters PM. Current concepts in the management of brachial plexus birth palsy. J Hand Surg Am. 2010;35(2):322–331. Article Summary on PubMed.
Revised by Sarah Lewis, PT, member of APTA's Academy of Pediatric Physical Therapy. Reviewed by an APTA section liaison.