Erb's Palsy

[prem]

Erb's Palsy

Hi, I'm treating a girl with birth palsy (right) aged 11. She is able to abduct her right shoulder actively to 90 degrees and can abduct to 160 if assisted. She has been taught resisted exercises for shoulder abductors. Electrical stimulation is not yet started. Please suggest me the mode of current and the method of stimulation to treat this patient and any other mode of treatment to increase her active abduction.

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[physiobob]

Hi Prem,

There are a few previous questions about Erb's palsy and one or two replies. Perhaps as time has past from those older posts the originators might now have more insight. Take a look in the tags section under Erb's Palsy to have a read or to contact one or two who have posted on this before.

best of luck

[sdkashif]

Kindly do the manual muscle testing of the muscles around his shoulder and shoulder girdle. Give assisted ROM exercises to muscles which have strenght of grade 2 and give graded exercises to muscles which have power or strenght of grade 3 or above. Give strenghtening exercises to muscles which has power around normal grade. You don't need to give electrical stimulation to muscles which have power or strength of grade 2 or above or muscles which show signs of sufficient activity or movement. However, you may warm up the muscles before exercise by giving Infra red rays for 20 -30 minutes to get a better response from prepared or warmed muscles. Also keep on doing the regular Passive ROM exercises in muscles or joints of upper limb to preserve muscle and joint ROM and elastibility and tp prevent the joint stiffness. Use splints only in those joints where there is sufficient muscle imbalance or impairment of the quality of movement of function. Just feed back us your results.

[emad]

I think there is no current evidence supports elctrotherapy in case lkike Erb,s or paralysi in general . Better to practise active motions , playing games ..balls with her upper limbs , if possible advise swimmimg practise .

Cheers
Emad

[prem]

i'll definetely follow ur suggestion and thank u so much for guiding me.i've observed the patient's forearm bulk is more than the normal one and the affected upperlimb is also short by 4 cm. the effected side elbow is in slight flexion.can we get the limb length to normal by stretching and strengthening the elbow extensors?

[sdkashif]

Yeah you should try to release the contractures at elbow by stretching and strengthening the weak muscles. Once the contracture is released, the upper limb affected will look normal in length.

[emad]

Personally , i see the issue of stretching and strenghtening can NOT provide the good outcome expected .
The key point is NOT the muscle ,but the behavior of the child regarding that limb ,Cortical attention toward that upper limb seems to be lost , sometimes they do NOT like that limb ....reach the level of hating it , usually they prefer using the non-affected .
Encourging them to use that limb is a social matter primarily .I begin to apply Induced constraint therapy early as possible ,i noticed great progress from the first 3 months of age .

Cheers
Emad

[sdkashif]

It is Ok with to induce the movement in the weak limb but where there is contracture, stretching has a definite role to play. By inducing the active movements in a limb is actually the way of strengthening the weak limb in other words.

[emad]

Stretching needs to be reviewed within physiotherapy and rehabilitation concepts ,because it fires protective mechanisms ( reflexes) leading more contractures . Just observe this child manner /pattern of activity ,you will find them move in pattern leads to that flexed contracture . This type of contracture was mysterous for me with one of those childern .Just non-cooperative child .

Cheers
Emad

[junior_physiotherapist]

hi sdkashif:

would u plz give more details on applaying eletrical stimulation on patients suffering upper motor neuron lesion!!!,i'm wondering if really there are referrences confirm this given....

with regards

[sdkashif]

Is there any evidence based study that verifies that stretching leads to more contractures? If there is any studies regarding that, kindly provide some links regarding that.

[emad]

Unfortunately , NO evidence .

Cheers
Emad

[ramywhite]

I don't know either if there is any evidence that stretching contracture tissue may lead to more contractures . But if the muscle is good innervated you can use Active Inhibition to overcome the patient active resistance to stretching.
Cheers

[emad]

Nice ,Why are we standing still believers in Stretching ? Is there evidence supports stretching efficacy in contractures .

Further behind step , anyone has experience that stretching could work in contractures .What is the cause of this contracture with that Erb,s girl ?

Cheers
Emad

[susie riddoch]

As an old physio who specialises in chronic shoulders I don't have any real paediatric experience but I did manage to obtain full range G/H movement in an old Erb's Palsy patient who was 14 and had similar range to your child.
The range was increased simply by doing myofascia releases around the bottom end of the scapula ( lat dorsi & teres major) with the girl in side lying and her arm up as high up as can be tolerated so that everything is on the stretch. She used the lower arm to support the affected arm which lay over her head once the range was increased. You must use good lubrication (I used sorbolene cream) and warn the child that it is a very uncomfortable procedure but that they have complete control over stopping the massage and only ever did 10 up and down strokes. Once she realised how much range she was gaining she took over the releases herself, putting her arm over her head in the shower every morning and doing 10 strokes. From memory I think it took 2- 3 months with me seeing her weekly, the first month, then fortnightly then monthly. A year later the range had not regressed.

[Aisha_kb]

Well, its all good in trying to increase the ROM for GH joint movements, i find that to be the easiest and quickest movement to attain using whichever technique.
The main deformity comes with the action of supination. These kids tend to always maintain a pronated forearm and getting the action of supination has never been successful for me. i have tried electrical stimulation of the biceps, supinators, passive/active-assisted ROM, contract-relax, even PNF patterns to try and get that movement.

Anybody faced the same situation?

[sana zehra]

hi i have treated a one month baby suffering from erbs palsy i gave her
e stimulation(+ve electrode on brachial plexus _ve electrode on innervation of c5)
exercises for supinaters and abducters
this girl has been fully recovered

[estherderu]

dear Zana,

Oh dear.....

How can you be so sure about it was your treatment that cured this girl?
I have been treating babies for many (31) years now and:
- I would never dare say I could find the "rights spot" to place both electrodes in such a young child,
- electrotherapy is (preferably) not used with infants at all,
- I wonder if you know about the guidelines there are for treating children with Erb´s palsy, ( have been published before on this forum )http://www.ubpn.org/awareness/A2002storment.pdf
- Do you know that many of the children (with neuropraxia) recover completely without therapy?

Go to the various forums related to this subject on this forum for more advice.

Please be very carefull with electrical agents while treating children. They are very often contra-indicated.

Kind regards
Esther de Ru

[bolarinwaayesa]

I have been handling a child with erb's palsy for about a month now. The improvement is moderate as expected because of the level of injury to the brachial plexus. If you can incorporate PNF techniques it will surely help. I am treating the child using exercise, massage, active assisted, and PNF. Just keep at what you are doing but incorporate PNF and you will see the much awaited improvement.

I particularly find the use of electro stimulation not suitable cos you really cannot tell when you are actually sending high level intensity into the baby's body considering the fact that baby's cannot give you accurate feedback.

It is well.

[bolarinwaayesa]

I guess Estherderu is righ. It is not only sensitive using those electrodes on children but dangerous as well. I believe in eercise therapy in managing erb's palsy. i have been treating quite a number of babies and returning with impressive improvement.

[estherderu]

dear Prem and others
quote"
i've observed the patient's forearm bulk is more than the normal one and the affected upperlimb is also short by 4 cm. the effected side elbow is in slight flexion.can we get the limb length to normal by stretching and strengthening the elbow extensors?"

The bulking could very well be a changing bone structure as a result of the changed traction of the "unbalanced muscles". We know the growing bone tissue reshapes as a result of the forces applied to it. If that is the case...I am afraid that no amount of stretching will change this.

kind regards
Esther

[bolarinwaayesa]

I believe the use of right techniques in managing erb's palsy patients is very essential. what estherderu described is not a common occurrence but it does happen. I believe that incorporating slight stetching as it is obtainable in PNF could help prevent such occurrence.

[syuhadah]

what is erb palsy and how they developed and what the couses of erb palsy.Is that the children with erb palsy have deformity,contracture or disability of movement.Also,which part of nerve supply that affected with erb palsy children.