BRACHIAL PLEXUS PALSY

What we mean by brachial plexus palsy in newborns is paralysis of the baby's arm that is visible immediately after birth.  It can be caused by numerous factors, but it usually occurs as a result of damage to the nerves that extend from the neck to the arm (the brachial plexus).  

WHAT DOES IT LOOK LIKE?

A healthy newborn flexes, extends and spreads out his arms.  However, when there is damage to the nerves of the brachial plexus he is unable to move one or both arms.  This damage can manifest itself in various ways - from small deficiencies in motor control to complete immobility of the arm.  

The clinical picture depends on the location and size of the damage.  There can be damage to the upper, middle or lower part of the nerve plexus, to a larger area or even to the entire brachial plexus.  

If there is damage to the upper part of the nerve plexus (called Erb-Duchene('s) palsy/ Erb's palsy), the baby's arm is held limply against his body and is turned slightly inwards.  The baby cannot lift his arm up, nor can he bend it at the elbow.  

It is an extremely rare phenomenon to have damage to only the middle part of the nerve plexus.  

Injury to the lower part (called Klumpke-Dejerine palsy/ Klumpke's palsy/ Dejerine-Klumpke palsy) is common in everyday life, but it is not as common as damage to the upper part of the nerve plexus.  Common signs are a limp hand that is turned downwards and a partial or total lack of movement of the fingers.  

When a larger area is affected or when all of the roots of the brachial plexus are injured it is called mixed palsy.  In this case the baby's arm is immobile, it lays limp beside the body and is turned inward while the baby's closed fist hangs or the closed hand is bent at the wrist. 

HOW TO HELP?

When the doctor establishes a diagnosis of brachial plexus palsy and excludes any other possible problems with the child, it is necessary to begin with a rehabilitation treatment programme.  The programme is created by a specialist for physical medicine and rehabilitation (a physiatrist).  

First of all, the arm is placed in a corrective position to protect the joints and to prevent incorrect postures.  It is possible to do this by lifting the injured arm and attaching the child's sleeve to a pillow with a safety pin and supporting the hand with a covered stick, for example a covered ice cream stick, or by placing a cotton ball in the baby's hand and securing it with a dressing.  It is better to use the cotton ball with dressing because it holds the baby's fingers in a soft, partially bent position.  The specialist will create a splint made from plastic for the corrective position.  With the splint the arm will be raised 90 degrees for upper part nerve plexus injuries and 80 degrees for lower part nerve plexus injuries and the hand will be held open with palm forward.  The physiatrist will decide when the splint will be used and for how long.  

A baby with brachial plexus palsy starts his fourth day of life with "medical gymnastics" (rehabilitation exercises).  There are different methods.  It is necessary to perform the exercises repeatedly every day on the child. The daily "dose" is three hours of work with the child.  Naturally, this daily dose is reached gradually.  Exercises are performed primarily to help the injured arm; however, exercises to stimulate overall motor control are also performed.  It is important to note that the child should be stimulated to rotate around the axis of his body by swinging his injured arm; when he can do this properly he is on the path towards normal motor development. Mastering the protective reactions in a sitting position comes next, then the four-legged position and crawling. While performing these exercises the weakened muscles of the injured arm are used and stimulated, and this promotes recovery. 

It is very important to handle your child in a specific way and to stimulate his injured arm in all daily situations.  Thus while nursing it is important to place your baby's hand on your breast and to press it lightly with the palm of your hand.  If your baby feeds from a bottle then before he puts the nipple into his mouth you should place his hand on the bottle and hold it in place with your palm.  In that way your child will connect holding his hand with something pleasant and after a while will start placing his hands on the bottle himself, and even holding it as much as he will be able to. In addition to this you should persistently try to put the thumb of your baby's injured hand into his mouth; it is good if he accepts this and starts sucking because then this is something that is "his".  This is very important because a child with brachial plexus palsy tends to leave his paralysed arm out of his overall body schema. At the same time you should be careful because your child may have an impaired sense of touch by which he will not feel anything if he bites himself.  It is also important to direct the child to bring his hand toward his mouth with his palm facing the mouth.  It is necessary to do this thousands of times for the child to accept it after several thousand times of practice. 

It is necessary to place your child in a prone position (on the tummy) leaning on both elbows and with fists open and while doing so to watch carefully that this position is maintained because of the disbalance caused by the weakened muscles.  If your child begins to cry or shows extreme displeasure, it is necessary to change his position and then to slowly try to get him accustomed to this position.  It is necessary to prompt your child to use his injured arm properly in all activities.  That is why planned play therapy is the method of choice for working with your child and it should be started as early as possible.  

Medical gymnastics, planned play therapy and handling your child in a specific way are the most important elements of treating a child with brachial plexus palsy.  With professional instruction a parent can carry this out by herself and in that way can help her child in the greatest and best way.  Of course, there are other treatment methods that are carried out in medical institutions, depending on the child's age and the nature of the injury.  However, even then, medical gymnastics, planned play therapy and handling the child in a specific way are the basics of the treatment. 

RESULTS OF TREATMENT

It is necessary to invest a lot of effort, faith and knowledge, and especially patience in order to achieve results.  The results of treatment, if the treatment is begun on time and properly, can result in recovery in about 40% of cases, while in the others visible consequences of the injury remain.  However, the more one works with the child, the fewer the consequences that remain.   

REMEMBER!

Brachial plexus palsy requires:

- beginning the treatment on time

- performing exercises (medical gymnastics) on the child as the most important treatment method

- handling the child in a specific way and carrying out planned play therapy

- a daily dose of three hours of treatment

- a lot of patience, love and faith that results can be achieved, which can be full recovery or at least reducing problems.