Saturday, November 12, 2011

Clinical classification of Erb’s palsy & it’s physiotherapy

Narakas classified babies with obstetric palsy into four groups
I. Upper Erb's palsy (C5, C6 injury)
II. Extended Erb's (C5, C6, C7 injury)
III. Total palsy (C5, C6, C7, C8 & T1 injury)
IV. Total palsy with Horner’s syndrome (C5, C6, C7,C8 & T1 injury)

Clinically however Narakas Group II can be sub-classified into two groups according to this 'early recovery of wrist extension.'

II a. recovery of Gr 3 wrist extension before 2 months of age.
II.b. recovery of Gr 3 wrist extension after 2 months of age.

II a recovers the UL function much faster than the II b group.

Muscles paralysed in Group I are: Biceps, Deltoid, Brachialis, Brachioradialis, partly supraspinatus, infraspinatus, Supinator.

Extended erbs palsy involves the elbow & wrist

Intrinsic muscles of hand & ulnar flexors are paalysed in total palsy

Horner’s syndrome comprise of: Ptosis, Miosis, Anhydrosis, Enopthalmus, Loss of ciliospinal reflex.

Sensory loss in Gr I & II may be in little area over deltoid.

Physical therapy approach in nut shell:

Therapy is the cornerstone in the management of the symptoms of a child with BPP brachial plexus palsy. Popular or conventional physiotherapy approaches include exercise therapy, tactile stimulation, soft tissue manipulation techniques and functional splinting. Recently functional stimulation is found better than common electrical stimulation (2).

Galvanic stimulation to the paralysed muscles. Libile method is used with faradic stimulation.

Exercise therapy:
A comprehensive program that includes stretching exercises, safe handling and early positioning techniques, developmental and strengthening activities, and sensory awareness should be developed and updated as needed.
For the first 2 weeks, the child may have some pain in the affected shoulder and limb, either from the injury or from an associated clavicular or humeral fracture. The arm can be fixed across the child's chest by pinning of his/her clothing to provide more comfort. However, some authors have discouraged this pinning in favor of immediate institution of gentle ROM exercises. Parents should be instructed in techniques for dressing the child to avoid further traction on the arm.
A comprehensive therapy program should consist of ROM exercises, facilitation of active movement, strengthening, promotion of sensory awareness, and provision of instructions for home activities. Overall goals should focus on minimizing bony deformities and joint contractures associated with BPP, while optimizing functional outcomes.

Splinting & taping:
Often a wrist extension splint is necessary to maintain proper wrist alignment and reduce the risk of progressive contractures even at 2 weeks period.
Static and dynamic splinting of the arm is useful to reduce contractures, prevent further deformity, and in some cases, assist movement. Commonly prescribed splints include resting hand and wrist splints, elbow extension splints, dynamic elbow flexion and supinator splints. Careful selection and timing of splint use is essential to optimization of the desired effect.

Taping techniques may be used by the therapist to control scapular instability and hence to promote improved shoulder mobility.

Contractures &stretching:
Severe contractures should be avoidable with consistent therapeutic exercises, including passive and active stretching, flexibility activities, myofascial release techniques, and joint mobilization.

Over time, these contractures can lead to progressive bony deformity and shoulder dislocation. Early and consistent stretching of internal rotators should minimize the risk of this problem. External rotation, performed with the shoulder adducted alongside the chest and with the elbow flexed to 90°, provides maximum stretch of internal rotators (specifically, the subscapularis) and the anterior shoulder capsule.
The scapula should be stabilized while stretching shoulder girdle muscles to maintain mobility and preserve some scapulohumeral rhythm. Early development of flexion contractures at the elbow is common and can be exacerbated by radial head dislocation caused by forced supination. Aggressive forearm supination, therefore, should be avoided.

Sensory awareness:
Sensory awareness activities are useful for enhancing active motor performance, as well as for minimizing neglect of the affected limb. Use of infant massage and drawing visual attention to the affected arm can be incorporated easily into play and daily activities. Weight-bearing activities with the affected arm in all positions not only provide necessary proprioceptive input but also can contribute to skeletal growth.


1. Al-Qattan MM et al; J Hand Surg Eur Vol. 2009 Dec;34(6):788-91. Epub 2009 Sep 28.
2. Okafor UA et al; Nig Q J Hosp Med. 2008 Oct-Dec;18(4):202-5.

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