What is the recommended rehabilitation approach for a 2-year-old child with Erb's (Erb-Duchenne palsy) palsy?

Rehabilitation for Erb's Palsy in a 2-Year-Old Child

For a 2-year-old child with Erb's palsy who has not achieved full recovery, implement an intensive rehabilitation program combining functional electrical stimulation with task-specific exercises targeting shoulder abduction, elbow flexion, forearm supination, and wrist extension, delivered 3 times weekly with home-based exercises, while simultaneously evaluating for surgical brachial plexus exploration if significant functional deficits persist.

Prognosis and Recovery Timeline

• The natural history shows 80-96% complete recovery, particularly when improvement begins within the first 2 weeks after birth 1
• At 2 years of age, if significant functional deficits remain (difficulty with active shoulder abduction, forward flexion, symmetric elbow flexion, and forearm supination), the child falls into the 4-20% who will not achieve spontaneous complete recovery 1, 2
• Mild limb shortening and atrophy are commonly observed in children with persistent deficits at this age 2

Optimal Rehabilitation Approach

Primary Intervention: Functional Electrical Stimulation

Functional electrical stimulation should be the preferred modality over conventional physiotherapy alone, as it produces significantly superior outcomes in all functional measures 3

• Electrical stimulation demonstrates statistically significant greater improvements in shoulder range of motion, elbow flexion, wrist extension, and arm circumference compared to conventional physiotherapy 3
• Treatment frequency: 3 sessions per week minimum 3
• Duration: Reassess progress every 3 weeks, with major functional evaluation at 6 weeks 3

Complementary Conventional Physiotherapy Components

The rehabilitation program must include 3:

• Active and passive range of motion exercises targeting the affected shoulder, elbow, wrist, and fingers 1, 3
• Tactile stimulation to affected muscle groups 3
• Soft tissue manipulation techniques to prevent contractures 3
• Functional splinting to maintain optimal joint positioning 3
• Task-specific practice incorporating the affected limb into age-appropriate functional activities 3

Specific Functional Targets to Monitor

Measure these variables at baseline, 3 weeks, and 6 weeks 3:

• Shoulder abduction range of motion 3, 2
• Elbow flexion strength and range 3, 2
• Wrist extension capability 3
• Arm circumference (measured 6cm distal to acromion process) to track muscle development 3
• Forearm supination 2

Surgical Consideration

If no meaningful functional improvement occurs by 3-5 months of intensive rehabilitation, surgical exploration of the brachial plexus should be pursued 1

• Surgical intervention may improve outcomes in children who show no recovery with conservative management 1
• At 2 years of age with persistent deficits, the child has already exceeded the typical 3-5 month decision window, making immediate surgical consultation appropriate if functional limitations are severe 1

Home-Based Exercise Program

• Parents must be trained to perform daily passive range of motion exercises and functional activities incorporating the affected limb 1, 3
• Home program compliance is essential to supplement the 3-times-weekly supervised therapy sessions 3
• Focus on preventing secondary complications including contractures, limb length discrepancy, and muscle atrophy 2

Electromyography for Monitoring

• Electromyography is valuable not only for diagnosis but also for objective evaluation of recovery progress 2
• Initial EMG should have been performed 2-3 weeks after birth to assess severity; repeat EMG can track reinnervation patterns 2
• EMG findings help guide decisions about continuing conservative management versus pursuing surgical intervention 2

Common Pitfalls to Avoid

• Do not rely solely on conventional physiotherapy when functional electrical stimulation is available, as this produces inferior outcomes 3
• Do not delay surgical consultation if the child shows plateau in recovery or severe persistent deficits at 2 years of age, as the optimal surgical window may have passed 1
• Do not neglect the unaffected limb - ensure bilateral activities to prevent compensatory movement patterns 3
• Do not underestimate the residual "waiter's tip" deformity - even mild deformities require ongoing attention to prevent progressive contracture 4