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Clinical Chiropractic (2008) 11, 7076

intl.elsevierhealth.com/journals/clch

LITERATURE REVIEW

Chiropractic care of a patient with Erbs Palsy


with a review of the literature
Joey D. Alcantara a, Joel Alcantara b,*, Junjoe Alcantara a
a

Private Practice of Chiropractic, Calgary, AB, Canada


Research Director, International Chiropractic Pediatric Association, Media, Pa
and Private Practice of Chiropractic, San Jose, CA, USA

Received 9 January 2008; accepted 3 April 2008

KEYWORDS
Erbs Palsy;
Birth trauma;
Chiropractic

Summary
Background: Descriptions of the inability of children to move their arms following
birth have been recorded since the days of Hippocrates. In industrialized countries,
the incidence ranges from 0.38 to 3.0 per thousand live births, making it a very
common injury in neonates and a clinically common presentation. Sentinel observations by Erb (due to injury to the upper brachial plexus) and Klumpkey (due to injuries
to the lower brachial plexus) now bear their names. Birth weight greater than 4000 g,
the use of forceps and a very difficult delivery are just some of the risk factors
involved. An alternative explanation for obstetric palsy may involve an irregular
contour of the posterior pelvis of the mother causing impaction of the posterior
shoulder of the fetus as it passes over the sacral promontory.
Although testimonials are replete in chiropractic on the successful care of patients
with various pediatric conditions, documentation in the scientific literature is wanting. To address this issue, we provide the following case report as a first step towards
establishing an evidence base for chiropractic management of the condition.
Case Presentation: The patient was an 8-year-old female with medically diagnosed
Erbs Palsy. She presented with the typical waiters tip deformity in the right arm.
Since birth, the patient had restricted range of motion in the right upper extremity at
all involved joints along with muscle rigidity despite long-term medical care. Her
condition affected several aspects of her life including interpersonal processes with
her peers at school and in her social environment.
Methodology: Single case report.
Intervention: The patient was cared for with site-specific, low amplitude, high
velocity chiropractic adjustments (Gonstead Technique) to sites of vertebral and
extravertebral subluxations as well as myofascial release of the right upper extremity.

This study was funded by the International Chiropractic Pediatric Association, Media, PA, USA.
* Corresponding author at: 327 N Middletown Road, Media, PA, 19063, USA. Tel.: +1 610 565 2360; fax: +1 610 565 3567.
E-mail address: dr_jalcantara@yahoo.com (J. Alcantara).
URL: http://www.icpa4kids.com

1479-2354/$32.00 # 2008 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.clch.2008.04.002

Chiropractic care of a patient with Erbs Palsy

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Outcome: Following 3 months of care, the patients range of motion was bilaterally
symmetrical and muscle tonicity had normalized. The patient was able to fully
participate in social and sporting activities, including rock climbing.
Conclusion: This case report demonstrates a single case in which a pediatric patient
suffering from obstetric palsy (i.e., Erbs Palsy) benefited from chiropractic care.
# 2008 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . .
Case report . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . .
Physical examination . . . . . . . . . . . . . .
Conservative management . . . . . . . . . . .
Chiropractic care of brachial plexus injury
Conclusion . . . . . . . . . . . . . . . . . . . . . . .
Conflicts of interest statement . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . .

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Introduction
Since the days of Hippocrates, descriptions of maladies afflicting mankind have included those of children with the inability to move their arms following
birth. In 1764, the first reference appeared in the
modern medical literature when Smellie described a
newborn infant with bilateral arm paralysis, attributed to birth trauma, which resolved days after
birth. In 1872, Duchenne de Boulogne coined the
phrase obstetric brachial plexus palsy when it
was discovered that excessive tractioning of the
brachial plexus during delivery was correlated to
upper extremity paralysis.1
The brachial plexus is an interconnection of
nerves, whose roots include the lower cervical nerve
roots C5C8 and the first thoracic nerve, T1. As these
nerves course through the anterior vertebral foramen, under the clavicle and towards the upper
extremities, they are easily injured by excessive
tractioning of the upper extremities or the head,
such as that taking place during the birth process.
Sentinel observations by Erb and Klumpkey followed
when Erb described what now bears his name Erbs
paralysis, which is due to injury to the upper brachial plexus. Klumpkeys paralysis was eponymically
attributed following description of similar injuries
to the lower brachial plexus.1
As with all healthcare providers, the consequences of birth trauma are of major interest to
chiropractors undertaking pediatric care. In this day
of evidence-based practice, we contribute to the
literature by describing the successful chiropractic
care of a patient with Erbs Palsy since birth. We
focus on several aspects of the disorder including its

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75

clinical presentation, risk factors, treatment


options and a review of the existing chiropractic
literature. In so doing, we hope to contribute to the
development of sound strategies in the care of
similar patients under the paradigm of pediatric
chiropractic.

Case report
The patient was an 8-year-old female with Erbs
Palsy since birth. The patients mother suspected
that the mechanism of injury during birth may have
involved the attending medical doctor pulling so
hard that the bed moved forward. Prior to presenting to one of the authors (JDA), the patient was
under standard medical management, consisting of
prescribed physical therapy since birth. Despite this
long-term care, the patient continued to experience
the consequences of Erbs Palsy. According to the
patient and her mother, the patients physical deformity and dysfunction restricted her ability to play
and participate in gym class. Additionally, her physical presentation and inability to fully function in
sporting and social activities caused her to be stigmatized by her peers.
With informed consent from the patients
mother, physical examination was performed; the
following findings were notable: on visual inspection, the patient demonstrated the pathognomic
waiters tip deformity of the right upper extremity; her right elbow was fixated in flexion at 308
and her right wrist in flexion at 408. Upon further
examination, there was noticeable scapular winging
on the right, which was made more prominent by

72

J.D. Alcantara et al.

pushing against the wall. Digital palpation of the


wrist extensors and flexors revealed muscular rigidity without tenderness to palpation, a finding that
was repeated in the muscles of the right shoulder
girdle. Active range of motion (ROM) was restricted
throughout the right upper extremity when compared to the uninvolved side. Her right forearm was
fixated in posture at 258 pronation (i.e., with
respect to the uninvolved side) although she could
pronate or supinate to end-range from its fixated
position. At her right elbow joint, motion (active (A)
and passive) ROM was restricted on both flexion
(AROM: 458) and extension (AROM: 1658). With
respect to the right glenohumoral joint, restriction
and asymmetry were notable throughout all directions on AROM (i.e., flexion 258, extension 108,
abduction 158, internal rotation 108 and external
rotation 108). Orthopedic testing was not performed
as the patients obvious deficits would act as confounders in the interpretation of a positive orthopedic test. Neurological examination revealed
generalized sensory deficit with respect to Type II
and pain and temperature sensations on the right
upper extremity. Myotomal testing was weak at all
levels on the right with deep tendon reflexes unremarkable. The patients mother was informed of the
examination findings and consented for her daughter to undergo a trial of chiropractic care.
The chiropractic care provided to the patient
involving high velocity, low amplitude (HVLA)
thrusts that may best be described as Gonstead
Technique.2 On the first visit, the patient was
adjusted at C1 (ASR or uX, X) and C7 PR ( Z,
+uY) in the seated position; T4 PR in the prone
position and at L5 PR ( Z, +uY) and the right PI
( uX) ilium in the side posture position. Furthermore, the right scapula was fixated and therefore
was adjusted with the patient prone. A force was
applied in the superior and inferior directions, contacting the superior and inferior poles of the right
scapula with an HVLA-type thrust to the right scapula. Following care, there was noticeable improvement in the patients right shoulder active ROM,
especially on abduction. The adjustments were followed by soft-tissue manipulation, aptly described

as myofascial release, of the right upper extremities. The wrist flexors and wrist extensor muscles,
the pronator and supinator muscles of the forearm,
the biceps and triceps muscles, the deltoid muscles,
the upper trapezius muscles, the suprascapular and
infrascapular muscles as well as the teres muscles
were addressed with this soft-tissue approach. In
addition to the rigidity that was quite noticeable on
palpation, the patient had a high tolerance to the
deep digital pressure applied during myofascial
release. From our experience with other patients
(adults or children), the amount of digital pressure
exerted to her was relatively high and yet she was
not the least bit uncomfortable. The patient
reported feeling no pain or discomfort whatsoever
during the adjustments or the myofascial procedure
during or after care.
The above-described approach to patient care
was typical of every visit with full spine adjustment
followed by myofascial release of the muscles of the
right upper extremity. The patient was scheduled
for care three times per week for 6 weeks followed
by a review and reassessment of her condition and
response to care. During the first 6 weeks, the
patient was also instructed to continue her physical
therapy exercises. Insofar as the patient and her
mother could describe, they involved resistive exercises in the pool. Following 6 weeks of care, the
patients overall condition had improved such that
her ROM in the right arm and shoulder had increased
(see Table 1). Additionally, strength in the right arm
had also noticeably increased as reported by the
patient. Given the patients positive response to
care, she was scheduled at the same frequency of
care for another 6 weeks. Following 3 months of
care, the patient was discharged, having full ROM of
the right elbow, wrist and shoulder as compared to
the uninvolved side. Also notable during her care
was that, with continued improvement (i.e.,
increased ROM and functionality), the patients tolerance to deep digital pressure became less and
less. The palpable rigidity she initially presented
with became less noticeable on palpation and eventually the muscle tonicity took on the same consistency as the uninvolved side. Long-term follow up

Table 1 Range of motion examination findings of the glenohumoral joints


Initial examination
Flexion
Extension
Abduction
Internal rotation
External rotation

Comparative (3 months post initial visit)

Left (8)

Right (8)

Left (8)

Right (8)

180
35
120
90
90

25
10
15
10
10

180
35
120
40
45

175
35
115
90
90

Chiropractic care of a patient with Erbs Palsy


with the patient was positive overall. The patients
parents were very happy with their daughters
response to care as indicated with a follow-up communication with the patients mother. The patient
had been doing well; so much so that she was able
to rock climb at a birthday party event with friends.
She was no longer stigmatized or hampered by Erbs
Palsy and was on her way to developing into a
confident, active young lady.

Discussion
The quoted incidence of obstetric palsy varies
within the literature. In industrialized countries,
the incidence ranges from 0.38 to 3.0 per thousand
live births.3 According to Dodds and Wolfe,4 obstetric palsy occurs less in newborns weighing <4000 g,
whereas it is three times more common in newborns
weighing >4500 g. This was attributed to the
increase in mean birth weight due to improved
prenatal care and shoulder dystocia, wherein the
fetus anterior shoulder becomes impacted on the
mothers pubic symphysis. On the other hand, a
recent study by Graham et al.5 found that Erbs
Palsy in the newborn may not be so closely linked
to birth weight and recognizable birth trauma. In
their study, half of the cases of Erbs Palsy occurred
in normal-sized infants without trauma noted at
delivery.
According to Shenaq et al.,6 unilateral upper
brachial plexus injuries are the most common, followed by total unilateral brachial plexus injury.
Bilateral injury and injury to the lower brachial
plexus are less common. They also suggest that
breech presentation may be a risk factor. The use
of instruments during delivery such as forceps or
vacuum extractors may further predispose to brachial injury. Difficulties during passage through the
birth canal, as in this case report, may further risk
injury.1,5
The mechanism of injury in obstetric palsy injuries is tractioning of the brachial plexus during
labour. This can be caused by tractioning of the
neck and one or both of the upper extremities in
such a manner that the angle between the neck and
the shoulder is forcefully widened.7 According to
Jennet et al.,8 approximately 45 N of force may be
used for a normal assisted delivery, rising to approximately 100 N in a neonate with shoulder dystocia.
The resulting tractioning injury may vary from neuropraxia or axonotmesis to neurotmesis and avulsion
of rootlets from the spinal cord. Involvement of
nerve roots C5 and C6 with or without the involvement of C7 is referred to as Erbs Palsy and the
patient presents with the classic waiters tip

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deformity with an adducted arm, internally rotated
about the glenohumoral joint. The wrist is flexed
and, if the C7 spinal nerve root is involved, the elbow
is also flexed. Such was the presentation of the
patient reported in this case report in which,
according to patients mother, the delivery was
difficult with the attending physician pulling with
such force that the bed moved. This is consistent
with the finding that obstetrics palsy is an unfortunate consequence of a difficult childbirth.9
In the absence of other precipitating events in the
case history, this was the mechanism that caused
forceful tractioning of the upper brachial plexus to
occur, resulting in the Erbs Palsy, which was diagnosed shortly after birth.
By contrast, lower brachial plexus injury results
when the infants hyperextended arm is delivered
with the head rather than before it. The injury is to
the C8-T1 spinal nerve roots and the clinical features
are poor hand-grasping but intact proximal muscles.7
Total brachial plexus injury involving the spinal
nerve roots from C5 to T1 is correlated to the use of
forceps or vacuum extraction. Although only the
second most common type of brachial plexus injury,
it is the most devastating, leaving the infant with a
clawed-hand deformity, a flailing arm and widespread sensory deficits.8 Regardless of the extent of
neural damage, nerve lesions present with the same
clinical features; thus, the severity of nerve damage
can only be assessed by evaluating the patients
recovery over time. Neuropraxia and axonotmesis
can recover completely, sometimes spontaneously,
whereas neurotmesis and root avulsion result in
permanent loss of arm function, which may lead,
in time, to the development of skeletal malformations, cosmetic deformities, behavioral problems,
and socioeconomic limitations.1014
According to the medical literature, early recognition of obstetric palsy and referral to the correct
treatment facility remains the best option for a
positive functional outcome. According to the Collaborative Perinatal Study,15 95% of children born
with obstetric palsy recover completely while the
remaining 5% have persistent symptoms and considerable handicap. In the case presented, the
patient had been under conventional physical therapy for 8 years but continued to be debilitated,
physically and socially, by her injuries.
Although the case presented did not involve
medicolegal proceedings, there is currently focus
as to the iatrogenic nature of the condition and
recent suggestions that obstetricians are not necessarily responsible for all brachial plexus injury.
There is now evidence of injury to the brachial
plexus occurring prior to birth through lying in an

74
abnormal uterus or by intra-uterine constraint.16
Nerve injury may also result due to an irregular
contour of the posterior pelvis causing impaction
to the posterior shoulder as it passes over the sacral
promontory.17 If such cases could be identified,
there are suggestions that chiropractic the Webster
technique may be of use in alleviating intra-uterine
constraint.18,19

Physical examination
As with any case, it is of paramount importance that
the clinician obtains a thorough history before commencing physical examination. For the patient presenting with obstetric palsy, this should include
obstetric history, mode of delivery and post-natal
health and care of the infant. It is also suggested
that a full body/full spine examination should be
performed. Inspection of the neck and shoulder
revealing swelling may indicate pseudoparalysis of
the upper extremities that may be mistaken for
brachial plexus injury. The limbs and their associated joints should be examined for the possible
presence of fractures and dislocations. Fractures of
the clavicle and the humerus are associated with
injuries to the brachial plexus. Subluxations of the
cervical spine with spinal cord involvement are also
common associations; for example, abdominal
asymmetry resulting from involvement of the phrenic nerve, resulting in paralysis of the hemidiaphragm, and ocular asymmetry associated with
Horners Syndrome. Dependent on patient age and
ability to follow instructions, active and passive
ROM of the upper extremities should be performed,
not only to assess the amount of dysfunction but to
provide an objective comparison measurement to
assess the response to treatment. Assessment of
motor and sensory function is also important as is
assessment of the autonomic nervous system: a cool,
dry skin may indicate the loss of sympathetic tone.

Conservative management
For any patient presenting to a chiropractor with a
medically diagnosed condition for which they are
receiving treatment, approach to patient management has always been to share the responsibility of
care when appropriate. In patients with obstetric
palsy, such a multidisciplinary approach is exemplified in this report. Management may include the
pediatrician, the pediatric neurologist, neurosurgeon, orthopedic surgeon, physical therapist, social
worker and, as advocated by this case report, the
chiropractor.
The prognosis for obstetric palsy is generally
considered to be very good, with complete or almost

J.D. Alcantara et al.


complete spontaneous recovery in over 90% of
patients.20,21,6 However, a review by Shenaq
et al.6 suggests that this figure is over-optimistic.
If normal function has not returned to the deltoid
and biceps muscles by 3 months of age, prognosis is
much poorer and surgical intervention is common,
most usually at 57 months.22 In the case presented, insofar as could be recalled by her parents,
surgery was never discussed, despite the continued
upper extremity dysfunction.

Chiropractic care of brachial plexus injury


A search of MedLine and MANTIS [19662007] was
made using the Boolean operators utilizing the
search subjects chiropractic AND (obstetric palsy
OR Erbs Palsy OR Klumpkeys Palsy). Non-English
papers and those detailing non-pediatric cases (18
years old) were excluded.
Harris and Wood23 presented the successful chiropractic care of a 5-week-old infant with medically
diagnosed Erbs Palsy suffering from complete
paralysis of the left brachium and antebrachium.
A long and difficult delivery was reported by his
mother due to shoulder dystocia with a significant
amount of manipulation being applied to both the
fetus and his mother by the attending physician.
Chiropractic care consisted of specific adjustments
to the spinous process of the C5/C6 functional
spinal unit (FSU). Interestingly, the authors also
report using the Russian electrical stimulation
protocol to tolerance limits to the affected
extremity but without detailing how this was
ascertained in such a young child. Passive exercises
involving stretching maneuvers of the neck and left
upper extremity and having the baby grasp his
parents finger with the left fingers were also
recommended.
Hyman24 described the successful care of a 2month-old female patient, again with medically
diagnosed Erbs Palsy. The birth of this patient
was described as very fast with a lot of force
applied during the delivery. The patients mother
reported to the attending chiropractor that, her
buttocks were lifted off the table by the force the
doctor was applying to the babys head. Chiropractic care was described as full spine care using an
Activator Adjusting Instrument25 at a setting of two
rings. The subluxation pattern adjusted on the first
visit and similarly with subsequent visits was: C1 ASR
( uX, X); C5 P ( X); T1 PR ( X, +uY); T9 PL (( X,
uY); and right PI ilium ( uX).
No other cases describing chiropractic intervention in Erbs Palsy were discovered and the condition
has never apparently been scrutinized by any form
of meaningful research.

Chiropractic care of a patient with Erbs Palsy


These two reports, in combination with the case
presented, are notable for the following salient
points. Firstly, the type of care employed varies
considerably from the HVLA thrust to the C5-6
FSU (we infer using Diversified Technique)26
described by Harris and Wood23 to the use of Activator Technique by Hyman24,25 and the Gonstead
Technique2 described in this case report. This suggests that varying techniques and amounts of force
may be suitable for pediatric patients with Erbs
Palsy.
Secondly, there was also considerable variation
of management protocols, running the gamut from
the specific, local segmental adjustment of Harris
and Wood23 to full spine care as provided by
Hyman24 in addition to adjustment of extraspinal
segments (i.e., the scapula) as reported in this
case. Various modalities and exercises were also
utilized.
Due to the inherent limitations in the design of
case reports, it is not possible to infer absolute
cause and effect in the case presented, although it
would seem unlikely that there would be coincidental spontaneous resolution in the timeframe of
treatment after 8 years of consistent signs
and symptoms; however, the role of placebo
effects, natural history, regression to the mean,
etc. cannot be eliminated without the use of
control subjects.
Further documentation of other cases leading to
higher level research design studies are needed to
fully elucidate the effectiveness and safety of chiropractic care in patients with obstetric palsy. As
with all case reports, the authors caution as to the
generalizability of the case reported due to the
above discussed confounders.

Conclusion
The case presented demonstrated that chiropractic
care in the form site-specific, HVLA thrusts to sites
of vertebral and extravertebral subluxations in combination with soft-tissue work may be beneficial in
patients with long-standing Erbs Palsy. Continued
documentation in the form of case reports/case
series as well as higher level research design studies
will determine the most effective approach to care
in such patients.

Conflicts of interest statement


There are no conflicts of interest with regards to the
authors of this paper, the writing of this paper and
the reported findings.

75

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