Section Two  Pediatric brachial plexus palsies
See DVD
Rehabilitation concepts for pediatric
brachial plexus palsies
Virginia S. Nelson, MD, MPH, Denise Justice, OTR, Lynnette Rasmussen, OTR,
Miriana G. Popadich, RN, MSN, FNP
SUMMARY BOX
1. Maintain passive range of motion in all upper
extremity joints—especially shoulder external
rotation (in both abduction and adduction) and
forearm pronation and supination.
2. Force use of the involved arm through the use of
informal (e.g., holding the other hand or putting a
sock or mitten on it) or formal (e.g., cast) constraint.
3. Encourage normal development, including crawling,
swinging from bars, and climbing using the arms.
4. Follow the adage “back to sleep, tummy to play” to
promote symmetrical development of the head.
5. Encourage neck rotation to both sides.
6. Splinting may be used during sleep, except for splints
used to protect “floppy” joints.
7. For infants and young children, parents and
caregivers should be the child’s primary therapists,
Introduction
The severity of neonatal brachial plexus palsy
(NBPP) ranges from mild nerve stretch injuries
with rapid recovery to nerve root avulsions with
minimal recovery. However, a significant number of
NBPP patients do not regain full arm function, so
the principles of rehabilitation remain constant:
maintain range of motion at all upper extremity
joints, encourage strengthening as much as possi-
ble, prevent compensatory movement patterns,
and, most importantly, promote normal develop-
ment of function.
Initial evaluation and intervention
Babies with NBPP are typically characterized by
arm weakness in the immediate neonatal period
© 2012, Elsevier Inc
DOI: 10.1016/B978-1-4377-0575-1.00012-5
CHAPTER 12 
with guidance from occupational and physical
therapists.
8. Recreational activities like swimming, dance, and
crafts projects can supplement formal therapy as
home exercise programs, and these activities are
often not viewed by children as “therapy.”
9. Children with brachial plexus palsy are often
functional, but this function is frequently achieved by
using compensatory movements. Thus formal tests of
function usually show that they are “normal,” even
when they do not appear normal on examination.
10. When evaluating a young infant for brachial plexus
palsy, remember to look at the whole child. Do not
overlook breathing difficulties, torticollis, or
developmental problems that may also be present.
due to trauma to the fetal brachial plexus at some
point prior to completion of delivery. Initial evalu-
ation for NBPP should take place as soon as pos-
sible after delivery when the infant is medically
stable. History should include details about the
mother’s pregnancy, labor and delivery with par-
ticular attention to maternal diabetes or gestational
diabetes, hypertension, method of delivery, difficul-
ties during labor and delivery, and Apgar scores.
Details of the infant’s neonatal course should also
be noted, including respiratory status and feeding
ability.
Physical examination of the infant should include
the following: general inspection, weight, length,
head circumference and growth percentiles, exami-
nation of both legs including hips, examination of
both arms, observation of respiratory pattern and
movement of the chest, observation for any signs
of pain at rest or while the infant is being examined.
 Section Two  Pediatric brachial plexus palsies
Figure 12.1  Horner’s sign.
Figure 12.2  “Waiter’s tip” posture (left arm).
Particular attention should be paid to examining
the eyes for Horner’s sign (ptosis, meiosis, and
anhydrosis; Figure 12.1), and to the resting position
of the neck in the supine and prone resting posi-
tions for torticollis and during active and passive
movement. Is neck strength normal for the patient’s
age? In addition, examination of the affected arm
should include observation in the resting position
for classic postures of NBPP (eg, Waiter’s tip; Figure
12.2), testing passive and active ranges of motion,
recording lengths and circumferences of all seg-
ments of the upper extremity, and estimation of
motor power of the arm and hand.
Is the child normal aside from the affected arm,
or are there other problems such as abnormal tone
in the trunk or other extremities, poor head control
for age, weak suck or uncoordinated suck and
swallow?
144
Table 12.1  Examination record for patients with neonatal
brachial plexus palsy
Examination:
Head shape and size
Eyes: conjugate movements, Horner’s
Neck: control in supported sitting and prone, range
limitations actively or passively
Chest: respiratory pattern, chest movement symmetry
Legs: range of motion, tone, movement pattern
Unaffected arm: range of motion passively and actively,
strength
Affected arm
Resting position
Passive range of motion
Active range of motion in supine and sitting or supported
sitting
Strength
Evidence of pain
Infant reflexes
Moro: symmetry
Asymmetrical tonic neck reflex (ATNR)
Feeding
Sucking, swallowing
Interaction with environment
Vision, hearing, touch
At the end of the examination, the following
questions should be answered and recorded
(Table 12.1):
1. Is the child normal except for the affected arm?
2. Is there Horner’s sign?
3. Is there torticollis and/or plagiocephaly
(Figure 12.3)?
4. What part of the arm is affected, and is it
mild, moderate, or severe?
If the initial evaluation is performed in an older
infant or child, gross and fine motor function and
language skills should be observed to determine if
further detailed testing is warranted.
Initial rehabilitation management
Following the initial evaluation, a treatment plan
should be made that specifies both short- and long-
term goals. Even if the infant may require nerve
repair/reconstruction, occupational and/or physical
therapy should be initiated to optimize outcomes
of surgical intervention. The infant who develops
early contractures will not recover function as well
as the child who has no contractures. The therapist
 Rehabilitation concepts for pediatric brachial plexus palsies
Figure 12.3  Plagiocephaly.
must formulate treatment planning strategies by
considering the upper extremity with regard to the
motor power of each muscle, potential safety pre-
cautions, functional recovery, and the long-term
psychosocial effects of NBPP. Proximal stability or
core strength is crucial and underlies good distal
mobility as well as fine motor and gross motor
coordination. It is absolutely essential for the thera-
pist to understand the anatomy of the brachial
plexus and the extent of stretch to the nerves in
order to develop appropriate short- and long-terms
goals of the treatment plan. Therapy evaluation and
treatment can and should begin as early as day-1 of
life, particularly in cases where the infant is medi-
cally stable.
A common presentation for the infant with NBPP
(primarily affecting the upper trunk) is a weak or
limp arm positioned in an internal rotation with
the shoulder adducted, elbow extended, forearm
pronated, and fingers and wrist flexed (Figure 12.2).
As the nerves of the brachial plexus regenerate,
motor function recovers. The course of recovery
for an infant with an upper trunk (Erb’s) palsy
includes slight shoulder flexion (often derived from
the pectoralis muscle), enough to flex the shoulder
to allow gravity to seemingly flex the elbow. Gradu-
ally, the infant learns to extend the wrist (Steindler
effect) or flex the fingers to aid and/or augment
elbow flexion (Figure 12.4). The focus of therapy
with infants at this point is to facilitate shoulder
flexion, particularly by abduction with external
rotation at the shoulder, and elbow flexion against
12
Figure 12.4  Using wrist extension to facilitate elbow flexion in
right arm (Steindler effect).
gravity. The timing for nerve repair/reconstruction
varies within the surgical community, ranging from
3 months to 9 months of age. Most practitioners
agree that recovery of shoulder flexion and abduc-
tion followed by elbow flexion against gravity
beginning by <3 months of age obviates the need
for surgical intervention. If clinical, electrodiagnos-
tic, and radiographic data are consistent with nerve
root avulsion injury, nerve repair/reconstruction
may be recommended as early as 3 months
of age.
The most important goal of therapy for NBPP
patients is maintenance of soft tissue and joint flex-
ibility. Passive range-of-motion exercises are critical
and must be taught to the parents/caregivers to be
performed routinely at home.1 These exercises can
be performed safely and effectively to gently stretch
the relevant muscles and joint structures to avoid
development of contractures (resulting from exces-
sive contraction of the functioning muscles that are
not counterbalanced by the paretic muscles).
Children with NBPP risk developing skeletal
deformities of the trunk and affected extremity due
to poor bone growth associated with weakness of
certain muscles, unopposed activities of other
muscles, or muscle imbalance (Figure 12.5).2 Poor
bone growth is a direct result of decreased weight-
bearing coupled with lack of muscle tension upon
areas of the bone that contribute to bone growth.
Infants
Motor training should begin as early as possible.
The purpose of motor training is to stimulate
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 Section Two  Pediatric brachial plexus palsies
A B
Figure 12.5  Musculoskeletal deformities (right arms).
activity in denervated muscles, to enable muscles to
be activated as soon as nerve regeneration has taken
place, to prevent or minimize soft tissue contrac-
tures, and to minimize ineffective substitution
movements. Motor training should continue for as
long as recovery is still occurring.
In the newborn period, the initial evaluation
should ascertain the presence of clavicle or humeral
fractures, respiratory problems, or other difficulties.
In one study, 1 in 11 newborns with a clavicle frac-
ture also had NBPP.3 In addition to evaluation of
arm function, assessment should also be made of
oral motor skills and feeding, head control, and
head positioning. In an unpublished study, 43% of
children under 6 months of age with NBPP also
had torticollis.4 Feeding difficulties may be due to
birth asphyxia, facial nerve injury, or breathing
problems, including phrenic nerve injury.5
In healthy newborns with brachial plexus palsy,
it is important to educate the parents on passive
range-of-motion exercises for all muscle groups.
These exercises should be performed at every diaper
change. Additionally, parents should be educated
regarding the need for “tummy time” at each
diaper change to promote symmetrical head rota-
tion and positioning. Torticollis is an abnormal
head posture including ipsilateral tilt, contralateral
rotation and translation,6 and it is the third
most common pediatric orthopedic diagnosis in
childhood.7 Persistent torticollis may lead to
146
plagiocephaly and facial asymmetry; deformational
plagiocephaly can be appreciated as early at 6
weeks of age with a preexisting diagnosis of tor-
ticollis.8 The major cause of deformational plagi-
ocephaly is limited head mobility in early infancy
secondary to cervical imbalance.9 For infants with
torticollis, parents should be encouraged to vary
the position of the infant’s head during play,
feeding, and sleeping. Use of positioning wedges
may be helpful. Home programs using neck
stretches to address tightness of the sternocleido-
mastoid muscle may be required for some infants
and should be taught to families by appropriately
trained therapists.
In some instances, a newborn will require a
hand/elbow splint prior to discharge from the hos-
pital. The indications for a hand splint are tightness
of the finger joints and/or significant atrophy of the
thenar eminence. If Horner’s sign is present, signifi-
cant atrophy of the thenar eminence is usually
present and indicates the need for a resting hand
splint. The preferable position for a resting hand
splint would be the intrinsic plus position (Figure
12.6). In the intrinsic plus position, the metacar-
pophalangeal joints are flexed at 60–70 degrees, the
interphalangeal joints are fully extended, and the
thumb is in partial abduction and flexion or
opposed to the extended interphalangeal joint of
the index finger. The wrist is held in extension at 10
degrees less than maximal.
 Rehabilitation concepts for pediatric brachial plexus palsies
A
B bearing positions developmentally appropriate for
Figure 12.6  Preferred “intrinsic plus” position for resting hand
splint.
An elbow flexion splint may be indicated if there
is subluxation. Extreme hyperextension of the
elbow reflects absent biceps muscle activity in the
context of intact triceps muscle activity, causing
muscle imbalance. Passive range-of-motion exer-
cises for elbow flexion should be performed with
careful attention to position of the forearm in supi-
nation or pronation (whichever position prevents
subluxation from occurring).
A newborn should not demonstrate pain during
range-of-motion exercises. If pain is present,
re-evaluation for skeletal injury should be under-
taken. Sequelae include sensory alterations associ-
ated with motor weakness. Sensory changes can
include absence of or impaired sensation in all or
part of the extremity, based upon which nerves were
involved during the initial stretch. With altered sen-
sation, hyperesthesia and allodynia is expressed in
the newborn with “fussiness.” Desensitization can
relieve the symptoms and can be achieved by the
use of firm touch versus light touch, the use of
infant massage, a variety of texture inputs from
fabrics, or vibratory input from infant toys.
When a clavicle or humerus fracture is present,
the arm should be immobilized using a sling with
the shoulder adducted and internally rotated and
elbow flexed at 90 degrees so that the arm rests
upon the infant’s chest for 3–6 weeks. The newborn
should be lifted by scooping the newborn under
the buttocks with one hand and under the head
with the other versus lifting the infant under the
12
axillae. Teaching a family to dress the involved
extremity first and undress it last may also prove
beneficial in reducing unnecessary movement of
the involved extremity during the healing phase of
the fractured area(s).
The NBPP therapy session begins with passive
range-of-motion exercises. Once the infant’s
muscles are stretched and prepared for activity,
elicitation of active range-of-motion exercises can
be encouraged by stroking, tapping, or vibrating the
muscle belly. Vibration can be used to elicit triceps
or elbow extension, deltoids or shoulder flexors/
abductors, or finger/wrist extensors. Elicitation can
occur in gravity-eliminated positions, progressing
to antigravity positions, and ultimately in weight-
the patient. Vibration/stroking can be used to elicit
biceps contraction or elbow flexion to achieve
movement patterns of hand to face or mouth,
elbow extension such as batting at toys overhead,
and wrist extension patterns to facilitate reaching
for toys. The therapy sessions should include inter-
ventions that facilitate the patient’s current level of
generalized development. The impact of the weak
arm upon developmental milestones should be a
major focus of every therapy session.
Infants with NBPP learn quickly to adapt to their
development with a unilateral bias. Progression
toward symmetrical development begins with
learning to roll prone to supine and back to both
right and left sides. A similar approach can be
applied when the child moves from supine to
sitting position. Once a child has learned to transi-
tion into sitting, progression to 4-point positioning
is appropriate. The strength and coordination
required to sustain and/or reach from the point
position is a precursor to crawling. Some infants
master the “commando crawl” while others will not
learn to crawl and will progress directly from sitting
to walking. Therapy techniques to facilitate crawl-
ing include the use of elbow supports/splints,
weight-bearing hand and/or wrist splints, shoulder
support splinting or taping techniques, or use of
positioning techniques9 combined with vibration
or, in some situations, neuromuscular electrical
stimulation. Protective reactions in the affected
extremity are often delayed or weak, yet they must
be a focus of therapy. A small therapy ball can be
used to develop forward protective reactions in
prone and sitting positions.
With the increasing popularity of the “back to
sleep” campaign, prone activities and neck rotation
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 Section Two  Pediatric brachial plexus palsies

skills must be encouraged to promote maximal func-

tion of the recovering muscles and to prevent
plagiocephaly. Tightness or contractures in the
sternocleidomastoid muscle can inhibit arm move-
ment. Release of contracture of the sternocleido-
mastoid muscle through stretching techniques, use
of inhibitory or facilitative Kinesio-taping (KMS,
LLC, Albuquerque, NM), and dynamic weight-
shifting activities can maximize development of
proximal stability within the trunk and shoulder
area. Flexibility throughout the neck and trunk is
imperative for optimal shoulder range of motion.
Symmetrical movement patterns facilitate motor
planning and proper development. A motor pattern
program should be initiated to avoid the inadvert-
ent establishment of compensatory motor patterns.
Neglect of the involved extremity can occur, so the
affected arm should be brought into the child’s
visual field as much as possible. Encourage the
child to explore the involved hand at midline with Figure 12.7  Reverse prop sitting.
the other hand and, if appropriate, encourage
mouthing of the involved hand. Precautions should
be taken as some children may bite the affected
hand. Toys such as play mats, overhead play gyms,
wrist rattles, toys that make noise or vibrate, and
light-weight rattles with small diameter handles
may be used at home to encourage bilateral
integration.

Toddlers
A toddler can be the most challenging patient age
in which to provide occupational/physical therapy.
Children in this age group prefer to learn activities
independently, and their attention span prohibits
concentration on one activity for long periods of
time. Carefully chosen play activities become the
mainstay of therapy. Weight-bearing activities such
as crawling through tunnels, rolling over the top of
balls, and side-sitting are possible to achieve during
guided play. For a child with weak rhomboid
muscles, or weak middle/lower trapezius muscles,
reverse prop sitting (Figure 12.7) is useful. Increas-
ing the demand of the activity to lift the buttocks
from the floor followed by the addition of forward
or backward motion will achieve “crab-walking”
(Figure 12.8).
Older children
At approximately 5 to 6 years of age, children
become aware of their own differences when
Figure 12.8  Crab-walking.
compared to their peers. Family support and
encouragement regarding function of the arm can
help in the transition to school. Physical education
class and outdoor recess can amplify differences
between the patient and his/her peers and lead to
avoidance. Climbing monkey bars, jumping rope,
throwing/catching balls, and using the swings
require the child to adapt to the activity, if he/she
is able to perform them at all. Some children may
return to seek therapy or other medical or surgical
intervention to increase active range of motion and
muscle power in the involved extremity.
A therapist within the school system should eval-
uate the needs of the child within the school setting.

148
 Rehabilitation concepts for pediatric brachial plexus palsies
A child with brachial plexus palsy will have diffi-
culty with the use of playground equipment, lunch-
room activities including opening containers and
carrying trays, use of computer keyboards and mice,
use of desk tools such as scissors, sharpening of
pencils and/or any other bimanual activity that will
disrupt the independent routine at school. Therapy
at this time should focus on independence, particu-
larly in age-appropriate functional skills that are
most important to the child and family.
Teenagers
Therapy for teenagers addresses activities that they
deem personally important, such as driving and
complex activities of daily living, in preparation for
transition to college or moving away from home.
Teenagers with poor function of the affected arm
may need to consider adaptive driving. The thera-
pist and physiatrist should be aware of the state
driving laws and approved adaptive driving equip-
ment. By adolescence, children have attended
therapy many times and are often uninterested in
formal therapy sessions. The therapist should be
considerate of this reality and incorporate age-
appropriate goals for the teenager.
Frequently, the teenagers will have shoulder inter-
nal rotation contractures and/or elbow contractures
that limit their ability to participate in complex
activities of daily living. Many teenagers have devel-
oped subconscious habits to accommodate their
arm weakness; they and their families are no longer
aware of their compensatory movements, so they
do not actively seek therapeutic options that may
improve their function. The therapist must remain
up-to-date with current available medical and surgi-
cal interventions that can be offered in the appro-
priate situation. Additionally, the therapist should
be looking out for overuse syndrome that is a
common result of subconscious adaptation.
Overuse syndromes can arise in the unaffected
extremity and, at times, in the affected extremity.
Overuse can manifest as carpal tunnel syndrome,
tennis elbow, shoulder impingements, scoliosis, or
back pain.
Selected treatment techniques
Many therapy options exist for the child with bra-
chial plexus palsy. Each technique yields different
results for different patients. Individualizing
12
Figure 12.9  Trumpeter’s sign (right arm).
treatment based upon the child’s response is
strongly recommended. To optimize arm function,
therapy should commence in infancy and become
a routine at home. With infants and toddlers,
therapy is performed through normal play with
purposeful movement patterning and hands-on
cuing. Sustaining interest and motivation with the
older child and teenager can be a challenge. Thera-
pists work hands-on with the patient or give verbal
cues to achieve a specific movement. To overcome
imbedded altered movement patterns, repetition of
more desirable patterning is encouraged at formal
sessions and at home, which requires the child and
family’s interest, motivation, and investment.
A major therapy focus is the recovery of full
passive and active range of motion, especially of
shoulder external rotation. Weakness of external
rotation and elbow flexion manifests as Trumpeter’s
sign (Figure 12.9). As the nerves and muscles
recover, motor memory for this altered posture per-
sists. Therapy focuses the patient and parent upon
activities that facilitate the appropriate motor plan-
ning to eliminate Trumpeter’s sign. Specific play-
based activities must be tailored to the individual
patient.
Compensatory patterns include hyperextension
or arching of the trunk, lateral trunk flexion toward
the unaffected side, or scapular elevation during
reaching activities. The use of mirrors is an effective
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 Section Two  Pediatric brachial plexus palsies
visual feedback tool for older patients to try to
extinguish these patterns.
Infant massage
Infant massage is commonly employed for patients
with brachial plexus palsy.10
Passive range of motion/stretching
Maintain the normal integrity of the joints through
the growing years to prevent contractures. Train
family members/caregivers in gentle and correct
positioning of the arm while performing passive
movements to avoid musculoskeletal complica-
tions. Integrity of the scapular relationship to the
humerus must be maintained in the normal move-
ment pattern to avoid unnecessary impingement on
the acromial process. Avoid over-mobilization and
over-stretching. If the stretch causes obvious dis-
comfort, modify the position as tolerated.
Myofascial release
Myofascial release is a common osteopathic manip-
ulative treatment technique that has been used to
manage thoracic outlet syndrome in adults and
may provide effective, noninvasive management of
brachial plexus palsy in neonates and infants.11
Symmetrical stretching of the pectoralis minor
muscle and clavipectoral fascia can occur by pas-
sively externally rotating the shoulders coupled
with abduction bilaterally.
Leisure interests
Home programs can be the most important part of
an effective therapy program. Educating families to
pursue leisure activities for their children within the
community that support the child’s psychosocial
needs and goals of therapy is a wonderful way to
optimize arm function and socialization. Suggested
activities include swimming, basic gymnastics (if
shoulder function allows), dance, martial arts,
archery, basketball, volleyball, baseball, and playing
musical instruments.
Activities of daily living
In the newborn, skin care is critical. Many patients
with brachial plexus palsy demonstrate an overac-
tive pectoralis muscle, which results in persistent
150
internal rotation and adduction of the shoulder in
addition to sensory alteration. Moisture is retained
in the deltopectoral crease resulting in rashes and
potential infection. Frequent range-of-motion exer-
cises, positioning of the arm in slight abduction,
and attention to appropriate skin care can maintain
the health of the infant.
Some children with lack of sensation of the hand
tend to bite their fingers or nails, especially when
teething. Alternatively, this biting behavior occurs
when nerve regeneration confers recovery of sensa-
tion or altered sensation of the limb and is the
child’s expression of discomfort.
The Wee-FIM is a measurement tool for activities
of daily living function in the pediatric population.
Older children with brachial plexus palsy readily
adapt to unilateral functioning or perform the
activities in compensated positions, so they may
score deceptively highly on this evaluation.
However, this tool can be helpful for younger chil-
dren to determine which activities of daily living
they may find troublesome. The Wee-FIM does not
represent complex activities of daily living, nor
does it reflect any emotional frustrations. An astute
therapist can detect issues that the Wee-FIM may
not.
Children should be taught to dress and undress
the affected side first. Adaptive devices for bathing,
dressing, grooming, hygiene, and eating may be
necessary. Adaptive shoe laces or one-handed
shoe tying techniques may be beneficial. Likewise,
use of loop or table mounted scissors may be
indicated.
The Pediatric Evaluation of Disability Inventory
(PEDI) self-care domain was administered to 45
children with brachial plexus palsy.12 Thirty chil-
dren had no hand impairment, 15 had hand
impairment. The group performance of children
without hand impairment was within normal
limits. The group performance of children with
hand impairment was more than 2 standard devia-
tions below the mean, and the difference between
the 2 groups was statistically significant. Children
without hand impairment did not have a self-care
activity limitation as measured by the PEDI. A
deficit in self-care ability was found in those with
hand impairment. The PEDI was able to differenti-
ate between the performances of reported self-care
activities of children with differing severities of bra-
chial plexus palsy; however, it was unable to dis-
criminate between those without hand impairment
and their peers.
 Rehabilitation concepts for pediatric brachial plexus palsies 12
Constraint encourage pronation in the patient unable to
pronate the forearm (Figure 12.11). Patients with
Edward Taub, a behavioral neuroscientist, devel- persistent wrist drop may benefit from a wrist
oped a technique termed Constraint-Induced cock-up splint (Figure 12.12). Commercially avail-
Movement Therapy.13 This technique is effective in able products may or may not be available for the
improving arm movement in adults after cerebrov- patient, and if not, these splints may be made of
ascular accidents and other neurologic injuries. low temperature thermoplastic materials, neoprene,
Current research is being conducted with children or bivalved fiberglass.
who have various neurological diagnoses. This In children who ambulate with significant shoul-
therapy technique consists of highly repetitive der weakness, a neoprene shoulder support (Figure
tasks, known as shaping of the involved arm, while 12.13) can allow the child to use the hand as
constraining the uninvolved arm so it cannot be opposed to a sling, which does not allow for elbow/
used. Regardless of the movement involved, the hand function.
common element is teaching the brain to “rewire” In an infant who is learning to crawl and who is
itself following injury. Taub’s studies have demon- incapable of wrist extension, a crawling mitt splint
strated significant improvement in quality of move-
ment and substantially increased use of the involved
extremity. A key factor with brachial plexus palsy is
the importance of minimizing neglect of the
involved arm. Because it is weaker and less sensate
than the noninvolved extremity, it is often neglected,
even when the involved arm has the function
ability to perform an activity. Whether a sock
attached over the noninvolved hand is used to
restrain an infant or a soft cast is used in a toddler
or older child, the objective is to promote increased
use of the involved arm. There are many approaches
to constraint therapy today with little research
regarding its timing, duration, effectiveness, and
long-term effects.

Splinting
Infants affected with a total brachial plexopathy
who exhibit an intrinsic-plus resting hand position
Figure 12.11  Pronation splint.
require a hand splint. Similarly, hyperextension of
the elbow is a reasonable indication for an elbow
flexion splint; a supination splint may be used for
an older infant or toddler who prefers forearm pro-
nation (Figure 12.10); and a pronation splint can

Figure 12.10  Supination splint. Figure 12.12  Wrist “cock-up” splint.

151
 Section Two  Pediatric brachial plexus palsies
Figure 12.13  Neoprene shoulder support.
Figure 12.14  Crawling mitt splint.
is indicated, with the thumb abducted, fingers
extended, and wrist extended between 70 and 90
degrees (Figure 12.14). Some children will require
palmar support to facilitate proper finger extension,
whereas others may require a rigid top to create a
clam-shell effect to maintain hand placement
within the splint. When appropriate, these splints
can be coupled with elbow support splints to
enable crawling.
Muscle stimulation
Neuromuscular electrical stimulation (NMES)
enhances muscle activation in weak or poorly
innervated muscle groups, primarily used for
patients with spinal cord injuries and cerebral palsy.
152
However, use of NMES as adjunctive treatment for
brachial plexus palsies has not been solidly estab-
lished. One randomized study involving 8 subjects
and 8 controls showed greater increase in shoulder
abduction, elbow flexion, and wrist extension range
of motion and arm circumference in those who
received NMES versus those who had conventional
therapy (not further described) 3 times a week
during a 6-week trial.14 NMES has been used for
many years in an attempt to excite paretic muscle
groups of the extremity affected by brachial plexus
palsy. One reported benefit of the stimulation is
that the infant becomes more aware of the extrem-
ity affected by the brachial plexus palsy. NMES or
functional electrical stimulation (FES) can be used
as soon as active muscle contraction is demon-
strated in the desired muscle, with the emphasis on
active training of the limb.2
Another study concluded that increased neu-
romuscular activity should not be recommended
immediately after motor neuron injury or in the
early stages of motor neuron diseases.15 The key
here is the time frame in which to apply activity or
stimulation. Certainly NMES or FES should not be
applied to muscles that are not demonstrating
muscle motor function, nor should this technique
be utilized during the initial/acute phase of the
brachial plexus palsy. When muscles demonstrate
reinnervation, there may be indication for the use
of NMES/FES. Current technology offers portable
devices that can provide NMES. NMES devices are
programmable to vary type of current, waveform,
pulse duration, pulse repetition rate, intensity, and
modulation.
Clinical judgment should be exercised in the use
of NMES or FES, and these techniques should be
used by a well-trained therapist who can instruct
parents in both appropriate use and precautions
(Figure 12.15).
Taping techniques
Kinesio-taping is an option in the motor training
of patients with brachial plexus palsy. Techniques
to inhibit muscles while simultaneously facilitating
other muscle groups are helpful. Taping techniques
can facilitate symmetry of the trunk and/or shoul-
ders. Inhibiting the pectoralis muscle while facili-
tating the deltoids or rhomboids can increase the
quality of reach in a patient with upper trunk
involvement of the brachial plexus. Kinesio Tape is
applied over the affected area with the muscles in
 Rehabilitation concepts for pediatric brachial plexus palsies 12

Figure 12.15  Neuromuscular stimulation.

a stretched position, from one end of the muscle to

the other with varying amounts of stretch to the
tape. For muscle support/facilitation, the tape is
applied from the muscle origin to the insertion; for
muscular inhibition, Kinesio Tape is applied from
muscle insertion to the origin. Taping is widely
used for a variety of conditions with varying results
(Figure 12.16). There is no scientific literature to
date concerning its use in brachial plexus palsy,
although anecdotal reports support it usefulness.

Botulinum toxin injections B

Botulinum toxin injections have been used to treat

spasticity in the management of muscle contrac-
tures. Although children with brachial plexus palsy
do not have spasticity, botulinum toxin has been
used in the treatment of contractures. One study of
22 children who still had contractures after serial
casting tried a combination of botulinum toxin
type-A (Dysport®) to the biceps brachii, brachialis,
pronator teres, and pectoralis major muscles com-
bined with serial casting of the elbow for 30 days.16
The results demonstrated significantly increased
elbow extension and 9-hole peg test scores, but no
change in Mallet scale or muscle power after 12
months.
Botulinum toxin injections to the triceps muscles
have been utilized to facilitate elbow flexion. When
the biceps muscle is weak and triceps strength is so
great that a significant imbalance occurs, the use of
the botulinum toxin may decrease this imbalance.
Anecdotal reports but no formal studies support
this application. Muscle imbalance is an ongoing
problem in children with brachial plexus palsy.
Figure 12.16  Taping for muscle support/acilitation.
When therapy treatment techniques reach a plateau,
additional interventions may be indicated, but
research is needed to determine exactly which tech-
niques are effective.
Pain management
One common problem in brachial plexus palsy is
pain, although its presence is difficult to detect in
infants and young children. An older child or teen-
ager may experience or express pain. Often, discom-
fort results from some type of repetitive overuse
movement, such as keyboarding or performing a
task at home or school. Treatment goals for the
child with pain include: (1) reducing the pain, (2)
determining the substituted movement patterns
that are causing the pain, and then (3) learning
to move more effectively – in such a way that

153
 Section Two  Pediatric brachial plexus palsies
minimizes pain as well as over-use of adjacent
joints during that particular task.
The initial focus is pain reduction. Stretches are
introduced. Pain is commonly seen in the levator
scapulae, rhomboid, and upper trapezius muscles.
A transcutaneous electrical neuromuscular stimula-
tor unit may be recommended. In addition to
reducing pain, Kinesio Tape can effectively facilitate
and/or inhibit activation of muscles. Frequently the
triceps, rhomboids, or biceps are taped for facilita-
tion. For example, if the biceps is found to be over-
firing and the triceps is weak, tape will be applied
to inhibit the biceps, along with tape to facilitate
the triceps.
Adaptive equipment
Adaptive equipment may be prescribed to reduce
pain. Computers, keyboards, and mice are now
standard communication tools used in the schools
and in many homes. A child with difficulty pronat-
ing the forearm will have impaired keyboarding
and mouse usage. Overuse and strain frequently
appear in the upper trapezius and levator scapulae
due to elevation of the shoulder to facilitate typing
and using the mouse with the affected arm. In addi-
tion to addressing the pain, the arm in performing
the task must be repositioned at the appropriate
height or distance to place the arm in a more
relaxed functional position. If pronation is difficult,
substitution use pattern may occur. In an attempt
to use the keystroke with the ulnar side of the ring
and small fingers, the wrist is strained to compen-
sate for poor pronation. Adapted keyboards better
position the affected arm for this highly repetitive
task. Depending on severity of the movement chal-
lenge, there are a variety of available products such
as a single-handed keyboard, a “tented” split key-
board that can vary the angle of the forearm posi-
tion, joystick mice where the forearm can remain
neutral, and a foot-driven mouse for those with
minimal hand function. Voice-activated word
processing is also available, but is typically not well-
accepted by teenagers.
Widening the scope of
treatment approaches
Active movement is very important to maintain
throughout life, particularly in patients with
154
brachial plexus palsy. All children, regardless of
ability or disability, should participate in some type
of satisfying sport or exercise. However, for children
with brachial plexus palsy, weakness, co-contraction,
and associated substitution movement patterns can
inhibit typical exercises and sports. Soccer is a
popular choice for a child with brachial plexus
palsy because it primarily involves the lower
extremities, but a lack of swing in the affected arm
when running is noticeable. The affected arm
remains stationary at the side with the elbow either
fully extended or flexed, while the other arm swings
naturally. Sports can be excellent teaching opportu-
nities for encouraging repetitive movement patterns
at a young age in order to establish new, more
beneficial patterns of movement.
Any bilateral activity is encouraged. Treatment
can incorporate marching, with purposeful swing-
ing of arms back and forth in an exaggerated
manner, to engage the momentum of patterning
the natural swing while walking or running. Drum-
ming is also an excellent bilateral activity with an
additional benefit of supination, which is one of
the more frequent challenging movements to
achieve. We encourage all of our families to swim,
because it involves all of the challenged muscles in
patients with brachial plexus palsies. It is worth-
while to invest the time, effort, and cost necessary
to find a good instructor who has the understand-
ing and skill needed to help the child succeed in
this particular movement pattern. If the child has
an interest in a sport, it becomes a great opportu-
nity because of their internal motivation. If possi-
ble, find a coach that is willing to provide private
lessons to encourage the child’s interest.
Group-based treatment may be beneficial for
older children for several reasons. The children and
parents respond positively to group activities. The
goals of group therapy include socialization, exer-
cise for fitness and core/extremity strengthening,
and refinement of gross/fine motor skills.
Socialization
Because NBPP has a relatively low incidence rate,
children with brachial plexus palsies rarely meet
other children with the same condition. When they
do meet, they appear very curious to compare their
arms with others and see how they move differ-
ently. They begin to see what others can achieve and
become inspired by one another. An additional
benefit involves the simultaneous development of
 Rehabilitation concepts for pediatric brachial plexus palsies
parental support and friendships as well. At times,
the parents will exercise with their children to the
great enjoyment of the children. Availability of
nursing and therapy staff encourages the discussion
of psychosocial issues as well as functional issues.
Exercise/movement
Although no formal studies support its use in chil-
dren with brachial plexus palsy, our session usually
starts with Pilates to provide mind/body awareness
in its approach to core strengthening activities.
Children with brachial plexus palsy tend to arch
their torsos to achieve increased shoulder flexion or
abduction, resulting in an anterior pelvic tilt and
shortened lumbar region. This compensatory move-
ment can lead to lower back pain. Focusing on
abdominal strength and core stabilization can
increase trunk strength and reduce the arch. Move-
ment patterns that challenge all the extremities are
not unlike the patterns developed with propriocep-
tive neuromuscular facilitation treatment, except
that they are more dynamic and fluid.
Fine motor skills
Group therapy includes a fine motor activity–
craft-making. The uninvolved arm can be restrained
to encourage use of the affected arm. Mimicking
peers who are facile at the task can improve
desired movements without emotional ramifica-
tions because they are with similarly affected peers.
Movement challenges continue throughout the
lives of patients with NBPP. The earlier they are
challenged to learn normal movement patterns, the
better chance they have to minimize habitual sub-
stitutions or even non-use of the extremity, and the
better chance they have to live productive and
satisfying lives.
Education
Education of the families regarding the anatomy,
clinical presentation, and treatment options for
brachial plexus palsy is crucial. The information can
be overwhelming and difficult to comprehend. The
emotional response may be similar to those of
families who are grieving a loss and may have sig-
nificant effects upon the mother’s postpartum
recovery. Fathers tend to react differently than
mothers, and their feelings cannot be discounted.
Appropriate communication with pediatricians and
12
other medical care providers of the patient (such as
social workers and neuropsychologists) can facili-
tate comprehensive care for the patient and family;
an interdisciplinary approach is often beneficial.
Nursing coordination of an interdisciplinary bra-
chial plexus clinic comprises an array of activities.
Setting and meeting patient and parent expecta-
tions is critical for maintaining high-quality care.
The parent usually expects a “cure,“ or the condi-
tion to be “fixed.“ Given the nature of the condi-
tion, the medical care providers’ expectations are
quite different. If communication between parents,
physicians, therapy providers, and nursing person-
nel is not straightforward or is lacking, patient/
parent expectations will not be met and trust in the
medical care providers will decline.
Educating the family about diagnosis, severity,
and prognosis in NBPP is the first step toward ful-
filling expectations. When assessing expectations,
the medical team must look at the patient’s needs,
the staff required to address the patient’s needs,
and the process of handling this type of patient.
The nurse coordinating the clinical care must con-
sider the education level of the family in order to
appropriately convey the complicated medical
information; the nurse coordinator can influence
change to improve patient health through clinical
education and communication for improved out-
comes.17 Educating parents/caregivers about avail-
able medical and surgical and treatment options
is necessary. Constant communication with the
parents/caregivers establishes mutual expectations
and more importantly, increases compliance.
A systematic approach aids in the education of
parents/caregivers. One paradigm consists of iden-
tifying the patient with a chronic or potential
disability, introducing the patient to an appropri-
ate clinic, assessing the physical/developmental
examination, assessing for biological risks, estab-
lishing the cost and the ability of the parents to
cover the cost, and lastly, setting and managing
expectations.18
Conclusions
Rehabilitation management of infants and children
with brachial plexus palsy benefits from an inter-
disciplinary team and comprises many techniques.
The overall goal of all treatment is to optimize
overall function, while minimizing contractures
and pain. Each member of a treatment team brings
155
 Section Two  Pediatric brachial plexus palsies
unique skills and biases concerning what is effec-
tive and what is not. Scant literature exists regard-
ing rehabilitation management techniques that
include even small randomized groups, let alone
large, blinded, randomized controlled trials. More
research regarding the effectiveness, timing, and
application of treatment techniques is required.
Until the results of such investigation are reported,
our best clinical judgment will determine the
optimal rehabilitative approach to treat the child
with NBPP.
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