Refer a child with a OBPI to a pediatric OT or PT who has had specific and recent
training immediately (within first few days after delivery) so that parents can be
educated and monitored in positioning, range of motion and precautions. The therapist’s
primary role should be to do everything possible to protect the alignment of the
shoulder joint while working on awareness/sensory input of the affected limb and
trying to keep the infant as symmetric (throughout the body) throughout development.
Frequency of treatment sessions may vary throughout the first few months depending
on recovery and how comfortable the parents and the therapist are with home program
follow through. Once movement begins to return, frequency may increase. For infants
who do not completely recover in the first month, a referral to a physician who specializes
in the treatment of children with OBPI should be considered within the first 3-6
months depending on the severity of the injury.
Probable outcomes based on early return of movement:
Hand and finger movement at birth has not been shown to be a reliable indicator of
recovery or outcome.
Generally if anti-gravity biceps is seen by 2-3 months, there is potential for full
nerve recovery by 1 year (Full recovery does not necessarily mean full function due
to residual deficits noted below).
If biceps function is seen by 3-6 months, there will be some strength and movement
If biceps returns after 6 months there will likely be severe impairment.
Biggest residual deficits (even when a full nerve recovery exists) are:
A misaligned and malformed shoulder joint due to muscle imbalances (an OBPI shoulder
can be posteriorly dislocated by as early as 6 weeks). The scapula can be so elevated
and protracted forward that it actually comes up and over the shoulder.
Over stretching of tight muscles and atrophy of weak/paralysed muscles.
Developmental motor apraxia/ no motor mapping for the affected limb due to disuse
and abnormal movement patterns from early on. Poor recruitment of muscles due to
In Erb’s Palsy (85% of OBPIs are classified as Erb’s Palsy), the muscles which are
strong and mostly unopposed are what cause deformities and orthopedic damage.
To minimize deformities and joint damage, we have to work to avoid activities that
promote strong internal rotation during the first 12-24 months of a child’s life.
Participating in therapy activities without providing appropriate shoulder alignment
will likely cause further damage.
Motor Development Issues: Prone tummy time is important, but once babies begin to
pull their arms inward to prone prop, they need to be taken out of full prone. Rolling
and side lying should be over the unaffected side with caution to protect the affected
limb. Getting in/out of sitting should be taught using the unaffected side. Crawling
should not be a priority in these babies. They typically will be expected to achieve
motor skills (including walking) later than usual. Emphasis on achieving typical
developmental motor milestones should be lessened.