Erb's palsy.pptx

Better understanding about common children's condition- Erb's palsy

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

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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 : decreased strength abnormal movement and function of joints muscular atrophy impaired bone growth 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- S ensation, 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 T o 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