OBSTETRICAL BRACHIAL PLEXUS PARALYSIS WHAT IS THE NETHERLANDS ERB’S PALSY FOUNDATION AND WHAT DOES IT DO? The Netherlands Erb’s Palsy Foundation (EPVN) is a foundation for patients with Erb’s Palsy and their families. The EPVN’s mission is to advance the education of both the public, medical practitioners and paramedics in the subject of Erb’s Palsy and the various treatments. In addition, the EPVN offers support groups where children and parents can share their experiences and talk about the condition. The EPVN organises lectures given by guest speakers and issues a bulletin three times a year, providing members with the latest information on Erb’s Palsy and available treatments. The bulletin also offers room for personal stories. For more information or queries, the EPVN has a network of people with first-hand experience with Erb’s Palsy that can offer support. WHAT IS ERB’S PALSY? Erb’s Palsy is a condition which, due to birth trauma, affects the primary nerves that supply the movement and feeling to the arm. Erb’s Palsy is officially known as ‘obstetrical brachial plexus paralysis’. The condition is however commonly referred to as Erb’s Palsy, named after the German neurologist Wilhelm Heinrich Erb who helped describe it. Erb’s Palsy refers to nerve damage in the upper plexus. A brachial plexus injury that occurs in a child’s lower plexus is called Klumpke’s Palsy, after the French neurologist who first described the injury, Augusta Klumpke. WHAT CAUSES ERB’S PALSY? Shoulder dystocia, a condition in which one of the baby’s shoulders becomes stuck under the mother’s pelvic bone during birth, is one of the main causes of Erb’s Palsy. During a head-first delivery, this would be the baby’s head. Because the angle between the baby’s head and shoulders becomes too wide, the nerves are stretched, causing injury. Even though a large and heavy baby is at greater risk, Erb’s Palsy can also occur for no apparent reason. Unfortunately, it is not possible to measure a baby’s size accurately prior to birth. Muscle weakness in babies (for example due to an early birth) or complicated head-first deliveries are also factors that can lead to an increased risk. In general it is said that Erb’s Palsy occurs in 1 to 3 out of every 1000 child deliveries. Recent studies indicate a higher percentage, namely 5 to 6 of every 1000 babies. WHAT ARE THE CONSEQUENCES AND WHAT IS THE PROGNOSIS? Nerves are responsible for the movement of muscles and transmission of feelings. If the nerves do not function properly, or not at all, the child’s arm will be fully or partially paralysed. Symptoms may also include lack of feeling or sensation in the arm. If the nerve damage is severe, the paralysis will be permanent, producing a functional or cosmetic handicap. Sometimes the nerves recover fully, without visible trace of the injury. However, in the weeks following childbirth, the course of the condition is difficult to predict and the prognosis uncertain. HOW TO TREAT ERB’S PALSY? 1. It is important that when the injury is observed, the child is taken to a children’s physiotherapist with experience in treating children with Erb’s Palsy as soon as possible. 2. It is generally a good idea to let the baby touch the affected arm as often as possible, for instance by letting both hands touch each other or by lifting the hand towards the baby’s mouth.
3. Moving the arm and changing position several times a day is also important. This will prevent the baby’s arm and shoulder from becoming permanently stiff. 4. To help the baby become aware of the affected arm, parents should touch and stroke the arm as often as possible. This, at a later date, may improve function of the arm. WHICH SYMPTOMS CAN OCCUR? Although the first weeks following childbirth do not provide assurance, the following symptoms generally indicate a less favourable prognosis: • a paralysed arm that has not fully recovered in two weeks; • a drooping eyelid (Horner’s syndrome); • complete lack of muscle control in the arm, or a thin arm (inertia and atrophy); • loss of sensation in the arm or hand, which can result in the child hurting his hand and fingers (auto mutilation); • paralysis of the diaphragm If one or more of the above symptoms are present, further tests should be performed. There is a risk of permanent paralysis, in which case the motor and sensory functions are completely lost. The brachial plexus is made up from five large nerves which come out of the spinal cord in the neck. These nerves are represented by the symbols C5, C6, C7, C8 and Th1. C5 is for shoulder abduction, C6 is for bending the elbow, C7 for straightening the elbow and C8 is for bending the wrist, and finally, Th1 controls the hand function. abduction sideways movement away from the centre of the body adduction movement toward the centre of the body external rotation rotation away from the centre of the body supination upward rotation of the forearm or palm of the hand pronation inward rotation of the forearm or leg WHERE TO GO FOR HELP It is very important that a child with Erb’s Palsy is treated by a children’s physiotherapist from the first week of life. The first weeks of treatment will focus on educating parents in handling and positioning their child. Then, advice is given on how to keep the child’s joints limber and the functioning muscles fit. If the arm has not regained movement after a period of 6 weeks, the child will receive further treatment at one of the following Plexus Brachialis Teams (PBWs): AZVU Amsterdam LUMC Leiden AMC Heerlen Department for Neurosurgery, Telephone: 020-4443714 Department for Neurosurgery, Telephone: 071-5263957 Department for Neurosurgery, Telephone: 045-5766652
Research and tests will pinpoint the location and severity of the injury. Based on the test results the neurosurgeon, together with a team of PBW specialists consisting of a rehabilitation specialist, and an orthopaedic and plastic surgeon, will be able to advise on the most appropriate treatment. If the injury is so severe that the child is not expected to recover reasonably well, surgery on the nerves may be required. This does however not mean that the child will recover complete function of the arm, but in most cases the function will improve. To prevent the arm, and in particular the shoulder, from becoming stiff during recovery, long-term physiotherapy treatment and routine check-ups by a rehabilitation specialist are required. A rehabilitation specialist in
your area can help you find a physiotherapist. In case of severe plexus injury, the child is likely to receive long-term treatment by one of the Plexus Brachialis Teams until maximum function of the arm is restored. It may be necessary to perform nerve repositioning surgery after a number of years. It goes without saying that the various treatment options will be discussed in detail with the parents. HELPFUL TIPS ON DAY-TO-DAY CARE The correct arm position during the first weeks There is not one correct position. In fact, parents should help their child move his arm as much as possible through a range of motion exercises. If the hand is placed in front of or against the baby’s mouth, the baby can suck his fingers. Allowing the two hands to touch each other can also create a pleasant feeling. Other positions are encouraged, such as moving the arm away from the body. This will prevent the shoulder joint from becoming stiff. Lifting and carrying A few things should be taken into account. Do not lift the baby by pulling his arms. Also try to keep the arm from falling down. Instead, lift the child by supporting his bottom with one hand, and shoulder and head with the other. When you carry the baby, position the affected arm across his chest, in between you and your child. Your body will then keep the affected arm in place. When in the nursing position, do not place the affected arm under your arm. And when you carry your child, turn the healthy arm towards you, and use one arm to support the affected arm and the other to support his bottom. Getting dressed and undressed There are no special instructions for getting dressed and undressed, but try to make the same motions with both arms. Only in case of a collar bone or upper arm fracture, the arm should not be bent forming a 90 degree or greater angle in the first three weeks. Finally Childbirth can cause the baby to experience stress or pain or be agitated. Stroking, cuddling and gently moving the baby’s affected arm is allowed, and even recommended. After several weeks, you can start with a range of motion exercises. Your physiotherapist and doctor will discuss the various exercises with you and give you advice. EPVN The EPVN has published a ‘Zorgboek’ containing information on Erb’s Palsy and how to cope with the challenges of this condition. Please visit our website for more information on how to order the book. You will also find a list of telephone numbers of our support network, and information on how to become a member or donate funds. Secretarial office Postbus 342, 6880 AB VELP Telephone: 06-53449407 Website: www.epvn.nl e-mail: info@epvn.nl
The Netherlands Erb’s Palsy Foundation image of how plexus injury can occur Sixth edition 2005 Foundation for patients with obstetrical brachial plexus paralysis and their families The EPVN has its registered seat in Utrecht, registration no. 40482339.