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Erb’s Palsy: Just a simple arm injury?
  • Jan 26, 2021
  • Latest Journal

Introduction to Erb’s Palsy
Erb's Palsy is a form of Brachial Plexus Injury. It is caused by damage to one, some or all of the five primary nerves that supply the movement and feeling to an arm. Each injury is individual and the damage can be partial or complete paralysis, depending on the trauma involved ranging from bruising to tearing (https://www.erbspalsygroup.co.uk/about-us/) Basit et al (2019) reported “It is a common birth injury with estimated prevalence ranges of 0.9 to 2.6 per 1,000 live births. It causes significant arm weakness that affects 0.4 to 5 in 10,000 births.” (https://www.ncbi.nlm.nih.gov/books/NBK513260/)

This birth injury is often caused by excessive pulling or stretching to the baby’s head and shoulders during a vaginal birth. Charter et al (2004) stated that controversy surrounded who was to blame for the injury, however many cases seek compensation through a medico legal claim.

An occupational therapist is an allied health professional who works with people with illness or disabilities to achieve independence in their daily life as far as possible. We look at a person holistically. Our assessment and treatment of occupation does not just cover a person’s job but all occupations in their lives from self-care, to domestic activities, to caring for others (e.g. children), to sport, leisure and social past times. We are therefore perfectly positioned to assess the impact an Erb’s Palsy has on a person’s life and to advise on equipment, therapy, adaptations, driving, leisure, schooling/employment and care/assistance which will place them as far is possible, in the situation they would have been if not for the material event.

At Somek and Associates, our assessment of the claimant involves discussion with him/her and their family, clinical assessment of motor, sensory and cognitive skills as well as observations of everyday functioning within their home and/or school environment. I am frequently asked by solicitors why I assess a claimant’s balance or why I ask about their psychological history, when the injury is related only to their arm. The reason is that every person is a holistic being. Injury or disability is rarely contained to one part of the person or their life. To demonstrate this, I have selected several case studies. Each was a claimant with Erb’s Palsy of varying severity, which impacted in different ways on their daily functioning.

Possible implications of Erb’s Palsy on the whole person
Cast Study 1: Just an arm, and a shoulder, and a back….
Jason* (all names have been changed for anonymity) was a man in his early 20s and I was instructed by the defendant. His Erb’s Palsy was severe and affected his right arm and hand. There was visible muscle wastage throughout his right arm and shoulder and his right arm was much shorter than his left. On clinical assessment, I noted that his posture was asymmetrical, the weakness in his right arm and shoulder had caused his right shoulder to drop. To compensate Jason continuously leant to his left side, causing further asymmetries throughout his spine and torso. He reported that he suffered from continuous back pain. Ridgway et al (2013) investigated that effects of Erb’s Palsy on postural control and found that of 32 children, 31 had postural control deficits, including asymmetrical posture and atypical movements. The article recommended that management of Erb’s Palsy should address motor development of the entire body. In this case, I considered it was important that the claimant had access to physiotherapy to address his postural asymmetries as part of a pain management programme.

Case Study 2: The use of upper limbs in balance
Lucy* was a secondary school student who had grown up in a bungalow. I was instructed by the defendant. Her left sided Erb’s Palsy was relatively mild, and she was able to complete many two handed tasks. However, on assessment, her balance skills were significantly delayed and she was unable to hop, balance on either leg or walk a line heel to toe. During each balance task, Lucy demonstrated no righting or saving reactions with her left arm and as a result frequently fell to her left. Her childhood in a bungalow had masked her difficulties with balance. During her first week of secondary school she had fallen down a flight of stairs and refused to complete any lessons on the first floor. Bellows et al (2015) found that the majority of their study population of children with Erb’s Palsy had significant difficulties with balance and advocated balance rehabilitation as a possible treatment for this patient group. My recommendation was a block of occupational therapy treatment to address balance difficulties, increase her confidence with descending stairs and liaise with school staff for access to lessons.

Case Study 3: Pain and somatosensory processing
Luke* was a primary aged child and I was instructed by the claimant. The nerve damage causing his left sided Erb’s Palsy was moderate, however due to his hypermobility it had had limited effect on his range of movement and motor function. Luke’s mother reported his biggest difficulty was sleeping.  Discussion with both Luke and his mother suggested that his disturbed sleep was the result of pain and altered sensation to his left arm, which would wake him multiple times per night. Further clinical examination of Luke demonstrated impaired tactile and proprioceptive processing through his left arm. Pain and altered tactile/proprioceptive sensation has been reported in cases of children with Erb’s Palsy (Annika et al, 2019; Brown et al, 2013). In this case, I recommended referral to a pain management specialist, equipment to maintain a comfortable position during sleep and protective equipment in the kitchen as Luke had decreased heat awareness in his effected hand and arm.

Case Study 4: Depression, anxiety and self-harming behaviours
Gemma* was a lady in her mid 20s with right-sided Erb’s Palsy. I was instructed by the defendant. Throughout my assessment, Gemma was very tearful in recalling her childhood, discussing multiple episodes of bullying as a result of disability. While completing a food preparation assessment, I noted several thick linear scars on her right forearm as well as several cuts and scratches. Further discussion with the claimant revealed that she had and continued to have issues with self-harming as a means of managing social anxiety and depression caused by her disability. Al Qatten (1999) found a small proportion of a sample of children with Erb’s Palsy suffered from self mutilation, while a study by Psouni et al (2018) reported a statistically significant higher number suffering from mental health disorders than their peers. My recommendation for this case was to refer to a clinical psychologist to assess and address the issues discussed in my assessment.

The individual and Erb’s Palsy
As stated in the opening paragraph each injury is individual, depending on the number of nerves damaged and the type of damage each nerve sustains. Every client/claimant I have met presents differently and not all have the difficulties mentioned above.

Case Study 5: Severity versus function
Alexander* was a boy in his early teens and I was instructed by the claimant. He presented with a left side Erb’s Palsy, with adequate movement and power in his left hand. However, the range of movement in his elbow and shoulder was minimal, resulting in his arm being fixed in an awkward looking position, held away from his body. Despite his presentation, on assessment, Alexander’s disability had little impact on his functioning. His balance was above average for his age, he completed all motor and functional tasks to an age appropriate standard and his parents helped him with no aspects of his personal care. In fact, he was a very helpful teenager and completed many domestic tasks around the house to earn pocket money. His parents reported he had many friends at school and he proudly showed me pictures of him and his girlfriend during the assessment. My recommendations were minimal and focused mainly on energy conservation to prevent future injury and maintain his level of function.

Summary
In summary, Erb’s Palsy should not be considered in isolation to a particular body part. In order to truly assess the impact on a person’s life, a complete and holistic assessment should always be conducted by a clinician with appropriate experience in the particular condition, to enable understanding of the cause of any particular aspect of disability, to determine management and functional prognosis. Each claimant’s injury is unique to that person and although medical records can indicate the extent and location of damage, this is not always indicative of functional outcomes. Effective and prompt therapeutic input and management of the condition in childhood is essential. This will assist in addressing functional difficulties that may escalate in adulthood if left. It is also important to note that the claimant’s social and physical environments will also impact on their ability to access activity and function. Occupational therapists are uniquely and ideally positioned to take all these factors into consideration on assessment. This ensures a holistic, robust and thorough evaluation of the claimant’s needs and subsequent recommendations for solicitors.


References
Al Qatten, M.M. (1999) Self-mutilation in children with obstetric brachial plexus palsy. Journal of Hand Surgery British and European Volume. 24(5):547-9.

Annika J1, Paul U2, Anna-Lena L3.(2019) Obstetric brachial plexus palsy - A prospective, population-based study of incidence, recovery and long-term residual impairment at 10 to 12 years of age. European Journal of Paediatric Neurology. 23(1):87-93.

Bellows D, Bucevska M, Verchere C. (2015) Coordination and balance in children with birth-related brachial plexus injury: a preliminary study. Physiotherapy Canada, 67(2):105‐112.

Brown SH1, Noble BC, Yang LJ, Nelson VS. (2013) Deficits in elbow position sense in neonatal brachial plexus palsy. Paediatric Neurology, 49(5):324-8.

M Chater, P Camfield, C Camfield (2004) Erb's palsy–Who is to blame and what will happen? Paediatric Child Health, 9(8): 556–560.

https://www.erbspalsygroup.co.uk/about-us/)

Basit et al (2019) via https://www.ncbi.nlm.nih.gov/books/NBK513260/

Psouni E1, Perez Vicente R2, Dahlin LB3,4, Merlo J2.(2018) Psychotropic drug use as indicator of mental health in adolescents affected by a plexus injury at birth: A large population-based study in Sweden.
PLoS One,13(3)

Ridgway, E., Valicenti-McDermott, M., Kornhaber L, Kathirithamby DR, Wieder H. (2013) Effects from birth brachial plexus injury and postural control. The Journal of Pediatrics. 162(5):1065-7.


About the author
Nicola White
has a MSc, BSc (Hons) in Occupational Therapy and qualified in 2005. Nicola is an Independent Occupational Therapist and Expert Witness for Somek & Associates, with expertise in paediatrics, Erb’s Palsy Autism and long term conditions. She is also a Case Manager for West Country Case Management.

Somek & Associates is one of the largest providers of Expert Witness services in the UK, and has over two hundred experts, which include occupational therapists (care experts), nurses, midwives, physiotherapists, speech and language therapists, and other allied health professions.

For more information about Somek & Associates’ Occupational Therapy experts – and all their other healthcare professional experts – please contact admin@somek.com or visit their website www.somek.com

 

 



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