In a newborn with Erb's palsy (C5‑C6 brachial plexus injury), what occupational therapy deficits are expected?

Erb's Palsy: Occupational Therapy Deficits in Neonates

Neonates with Erb's palsy (C5-C6 brachial plexus injury) present with a characteristic limp arm hanging from the shoulder, with the wrist and fingers flexed due to weakness of muscles innervated by cervical roots C5 and C6, resulting in profound deficits in shoulder abduction, elbow flexion, forearm supination, and wrist extension. 1

Primary Motor Deficits

The core occupational therapy challenges stem from specific muscle group paralysis:

• Shoulder dysfunction: Inability to perform active shoulder abduction and forward flexion, which are essential for reaching and upper extremity positioning 2
• Elbow flexion weakness: Absent or severely limited active elbow flexion against gravity, which is the critical prognostic indicator at 4 months of age 3
• Forearm supination deficit: Impaired ability to rotate the forearm, affecting hand positioning for functional tasks 2
• Wrist extension weakness: Compromised wrist stability and positioning for grasp development 4

Functional Impact on Development

These motor deficits translate into specific occupational therapy concerns:

• Asymmetric movement patterns: The affected arm hangs limply, preventing bilateral hand use and symmetric developmental activities 1
• Delayed grasp development: Hand asymmetry becomes particularly observable when infants attempt complex motor skills like grasping, even though early rudimentary skills (smiling, swallowing, head control) may be preserved 5
• Limb length discrepancy: Mild shortening and atrophy of the affected limb develop over time without intervention 2
• Secondary contractures: Uninvolved muscle groups develop contractures, and shoulder/elbow subluxation or dislocation can occur, further limiting function 6

Assessment Priorities

Occupational therapy evaluation should focus on:

• Active range of motion: Particularly shoulder abduction, elbow flexion against gravity, and forearm supination as key functional indicators 3, 2
• Arm circumference measurements: Document atrophy by measuring 6cm distal to the acromion process 4
• Bilateral hand use: Observe for compensatory one-handed task completion and hand preference asymmetry 5

Early Intervention Framework

The critical window for spontaneous recovery is the first 2 weeks, with 80-96% complete recovery rates if improvement begins early. 1

Treatment priorities include:

• Immediate immobilization initially: Followed by passive and active range of motion exercises, though evidence for intervention effectiveness remains limited 1
• Functional electrical stimulation: May provide superior outcomes compared to conventional physiotherapy for early functional resolution, particularly for shoulder range of motion 4
• Prevention of secondary complications: Focus on maintaining joint mobility and preventing contractures in uninvolved muscle groups 6

Prognostic Indicators

The presence or absence of active elbow flexion against gravity at 4 months of age is the decisive factor:

• Infants with active elbow flexion by 2 months demonstrate complete spontaneous recovery 3
• Those achieving elbow flexion by 3 months have satisfactory spontaneous recovery without requiring secondary procedures 3
• Infants lacking active elbow flexion at 4 months require surgical exploration and have poor hand function restoration prognosis 7, 3

Common pitfall: Assuming all cases will resolve spontaneously—while most do, 4-20% will not recover completely, and delayed recognition of surgical candidates (those without elbow flexion at 4 months) compromises outcomes. 1, 3