For Nurse Practitioners / Physician Assistants

For the nurse practitioner or physician assistant seeing the patient with brachial plexus palsy-- we suggest the following paradigm for your initial evaluation, conservative management, and/or referral to a specialty BPP Center.  The initial evaluation of the adult with suspected BPP includes a thorough History and Physical examination to:

  1. establish the diagnosis of BPP,
  2. evaluate for and treat associated conditions, diaphragmatic palsies, skeletal fractures, and other organ injury.

Early education and open communication with the patient and their family can improve the outcomes for BPP patients. 

History (HPI)

The history suggested below assesses for parameters that may be associated with BPP. 

Patient’s History

  • Onset of symptoms (neurologic deficit/pain)
  • Location (upper extremity/side)
  • Duration (how long has the patient experienced the symptoms and was it immediate after injury; symptoms improving or worsening?)
  • Character
  • Aggravated by
  • Relieved by
  • Frequency of occurrence
  • Severity of Symptoms
  • fractures of the humerus or clavicle
  • difficulty with breathing
  • ICU admission
  • other co-morbidity diagnoses
  • immediately after injury, presence of movement at 
        • Shoulder
        • Elbow
        • Wrist
        • Fingers
        • Thumb


The examination suggested below can supplement the standard examination.


  • Asymmetry of eyes (droopy eye/ Horner’s syndrome)
  • Asymmetry of chest expansion with breathing
  • Spontaneous movement of arm at       
        • Shoulder
        • Elbow
        • Wrist
        • Fingers
        • Thumb

Motor Function

  • Passive movement
  • Clicking or resistance when arm moved by examiner
  • Full or decreased range of motion when arm moved by examiner
  • Wrist movement
  • Finger movement
  • Thumb movement
  • Active Movement
  • Arm moves out to the side (like snow angel)
  • Bends elbow (brings hand to mouth)
  • Straightens elbow (lifts arm off face when supine)
  • Wrist bending / wrist extending
  • Make fist
  • Opens hand
  • Shoulder movement
  • Biceps movement
  • Triceps movement
  • Index finger movement
  • Pinky finger movement
  • Thumb movement
  • Sensation

Ancillary Testing

Radiographic imaging (MRI, CT myelo, US) can be useful to assess the extent and severity of BPP/PN injury. X-rays may be useful if skeletal fractures are suspected. Electrodiagnostic (EDX, NCV, EMG) testing of infants with BPP is a very specialized study, best performed at a specialty center with an experienced electrodiagnostician. Many published reports indicate that EDX may be overly optimistic, so the EDX must be taken in the context of the clinical history and examination. Interpretation of the EDX findings are quite difficult, and use of the EDX to determine prognosis remains controversial. MRI of the infant brachial plexus is a specialized study, best performed at a specialty center. Ultrasound of the infant brachial plexus is a specialized study, best performed at a specialty center by an experienced ultrasonographer CT and/or CT-myelogram is becoming obsolete as MRI carries fewer risks.    

The Next Step

Occupational /physical therapy (OT/PT) referral should be provided to encourage retention of full range of motion at all joints and to reduce the risk of contractures. Regardless of the extent and severity of BPI/PNI, OT/PT should be started as soon as possible, except in the presence of skeletal fractures. Home exercise program should be instituted with guidance from OT/PT . Those patients who do not demonstrate increasingly substantial recovery by 3 to 6 months after injury, referral to a BPP specialty center can improve the functional outcome of the patient. Options for specialty care include more complex conservative management and surgical interventions for nerve reconstruction, tendon transfers, and skeletal stabilization. If you would like to refer your patient to our specialty center, please click here.