The Cause and The Cure
Audience: Medical students in pre-medical school
A. Brachial Neuritis, definition
B. Brachial Plexus, definition
B. Physical therapy
Though the cause is unclear, many researchers and physicians agree that
surgical procedures and immunizations are possible causes of brachial neuritis.
Those who are diagnosed with brachial neuritis, depending on the severity of the
disorder will have available different medications and alternative treatments used
to help combat this disorder.
What is brachial neuritis? Brachial neuritis is a condition involving
decreased movement or sensation in the arm and shoulder caused by impaired
function of the brachial plexus, a nerve area that affects the arm followed by
several days of severe pain and discomfort (Health Central 1). The common
diagnosis of patients with acute brachial plexus neuritis is severe,
acute, burning pain in the shoulder and upper arm with no apparent cause. On
occasion, it may awaken the patient from sleep. In the majority of patients, the
pain subsides over the next few days to weeks, resulting in a weakness
in the upper arm--at times to the point of muscle flaccidity. The profile
of initial arm and shoulder pain followed by muscle weakness as the pain subsides
is an important characteristic of acute brachial plexus neuritis (Miller, Pruitt, and
The brachial plexus is part of the nervous system that is a channel for the relay of
sensory and motor impulses between the central nervous system on the one hand
and the body surface, skeletal muscles, and internal organs on the other hand, and
is composed of spinal nerves, cranial nerves, and certain parts of the autonomic
nervous system. The brachial plexus nerve pathways are made up of neurons (that
is, nerve cell bodies and their axons and dendrites) as well as the points at which
one neuron communicates with the next (that is, the synapse). The structures
commonly known as nerves (or by such names as roots, rami, trunks, and
branches) are actually composed of orderly arrangements of the axonal and
dendritic processes of many nerve cell bodies (Haines 1). Brachial neuritis occurs
when there is damage to the brachial plexus, the area where the nerve from the
spinal cord splits into the individual arm nerves.
Damage to the brachial plexus is generally related to a direct injury or
trauma to the nerve, stretch type injuries (such as a jerking of the arm), pressure
caused by injuries in the area of the brachial plexus. Causes may be related to
pressure congenital abnormalities tumors, or injury by toxins, chemicals, or drugs
(HealthCentral 2). Some doctors and nurses believe the actual cause of brachial
neuritis, is that while receiving an immunization, or during surgery the brachial
plexus nerve ending has been hit during these procedures (Reneer ).
In the report "Following Routine Childhood Immunization for Diphtheria,
Tetanus, and Pertussis (DTP): Report of Two Cases and Review of the Literature"
by Aline Hamati-Hadad and Gerald Fenichel. This report examined the picture
of this disease in two infants and emphasized the prognosis and its occurrence
after tetanus toxoid immunizations. Brachial neuritis was once known as serum
neuritis due to complications from passive immunization against tetanus, using
horse serum. Incidence reduced since the use of active immunization with tetanus
toxoid. "The Institute of Medicine, in its report on Adverse Events Associated
with Childhood Vaccines, indicated that the evidence favors casual association
between tetanus toxoid administration and the subsequent development of
brachial neuritis". The infants described in this report were healthy and were
of normal health and had received different diphtheria, tetanus, and pertussis
(DTP). This condition is benign with spontaneous resolution, there is the
possibility of recurrence with repeated vaccinations. Completion of the routine
immunization schedule is unlikely in most children (Hamati-Haddad and
Fernichel 3). Though many would disagree to this statement, most in the
healthcare business believe that immunizations are needed and the results far
outweigh the risks (Reneer). Brachial neuritis does not occur spontaneously
during infancy. All affected infants and most adults with brachial neuritis recover
rapidly and completely. Brachial neuritis is a self-limited disease that does not
require treatment. Early use of oral or corticosteroids and the use of physical
therapy has not been shown to alter the course (Hamati-Haddad and Fernichel 3).
While Miller, Pruitt and McDonalds’ study "Acute Brachial Plexus
Neuritis: An Uncommon Cause of shoulder Pain." examined a 66-year-old man
who presented with the complaint of severe, left-sided neck pain that radiated
into the left shoulder, without associated numbness or tingling. The pain had
begun one week earlier. Several weeks before he was examined, he had received
a flu shot. The patient’s symptoms resembled another disorder known as cervical
radiculopathy for which the treatment is significantly different. After several
weeks of from the onset of the symptoms the patient underwent an
electromyogram and nerve conduction studies. The results were consistent with
brachial neuritis. Brachial plexus neuritis has been recognized as a disorder since
the 1940s (Miller, Pruitt, and McDonald). Researchers have thought that viral
infection precipitates brachial neuritis but in 25 percent of these cases, various
infections proceeded the disease (Miller, Pruitt, and McDonald 3). "Up to 15
percent of the cases have been reported to occur following vaccinations" (Miller,
Pruitt, and McDonald 3). Evidence suggests, then that this disease is an
Dianna Quan’s report "Neuralgic Amyotropy: Presentation of a Case and a
Review of the Syndrome." Discusses a 36-year-old woman, a patient who had
been in good health prior to 1986 when, a few days after gall bladder surgery, she
noted left arm pain, weakness, and numbness (Quann 1-2). At that time, an MRI
of the cervical spine and electrodiagnostic studies were reportedly consistent with
brachial plexus neuropathy. In October of 1988 the patient was not able to
resume her job as a police officer due to the complications brought on by brachial
neuritis. Her condition remained the same until February 1993 when she hurt her
back after some heavy lifting. She then had surgery to repair a herniated disc.
Ten days after her surgery, she noticed mild tingling sensations in the tip of the
right thumb, which progressed over the next day to include numbness in the entire
thumb. Two days later, there was sharp pain in her right forearm. Abduction of
the shoulder exacerbated the pain. Twenty days after the onset of the latest
symptoms, she had partially improved, after taking the medication naproxen,
twice daily (Quann 2).
Treatment can vary depending on the case and the severity of the
complications. If the injury is minor, recovery may occur in a short time. During
the recovery of nerve function, treatment is aimed at pain control, maintaining
muscle power, and range of motion of the affected arm. Strengthening exercises,
range of motion exercises, and splinting may be helpful. Surgical repair is
considered for severe brachial plexus injuries. Treatment is based largely on the
symptoms, and opiate analgesia often is necessary in the initial period.
Immunosuppressive therapy (e.g., steroids, immunoglobulin, and plasma
exchange) has not been shown to be beneficial (Ashworth 7). The medications
used can very from Acetaminophen (Tylenol, Panadol, Aspirin free Anacin) to
corticosteroids. Over the counter or prescription analgesics may be needed for
pain. Various other medications might be used to reduce stabbing pains that
some patients have experienced, including phenytoin or antidepressants such as
amitriptyline (Healthcentral 3). Acetaminophen is prescribed when the patient is
only feeling minor pain and discomfort. For those patients that fit into this
category need to be advised that there are drug reactions if the patient is taking
some type of barbiturate, taking these medications together may increase the
toxicity of these medications. Patients who suffer from moderate to severe pain,
might be prescribed Hydrocodone or Vicadin. If taking these medications make
sure that it is not in use with such medications as phenothiazines, this will
decrease the pain relieving effects. Other medications for those suffering from
moderate to severe pain are the Oxycodone and Percocet family of drugs. As
with Vicadin and Hydrocodone, phenothiazines can also reduce the pain relieving
effects (Ashworth 8-9). In the case of the 66 year old man he was prescribed
Medrol, hydrocodone and Flexeril. He underwent physical therapy for three
weeks, and his condition slowly improved; however, he still experienced some
mild difficulty with shoulder abduction for several months. Whenever possible
the use of medications should be avoided or minimized to reduce the possibility
of side effects (Healthcentral 4).
For those patients where the pain is so unbearable that medications are not
helping, surgery may be the only recourse. Nerve grafting or tendon transfers may
be considered for the few patients who do not recover after 2 years of treatment.
Surgery generally aimed at improving shoulder abduction (Ashworth 7). Surgery
might be necessary if the disorder is chronic (long term), if symptoms worsen of
if there is difficulty with moving the arms, or if there is evidence that the nerve
has degenerated. Surgical decompression may relieve a trapped nerve, or surgery
may remove lesions that cause pressure on the nerve. Surgery has shown to help
some cases. Consultation with a physician before any surgical procedure is
performed. (Healthcentral 3).
Physical therapy should be focused on the obtaining a full range of
motion in the shoulder and arms. Passive range of motion and active range of
motion exercises should begin as soon as the pain has been controlled adequately, followed by conditioning of the affected areas. Strengthening of the rotator cuff
muscles and shoulder stabilization may be indicated. Passive modalities (e.g.,
heat, cold, and electrical nerve stimulation) may be useful as adjunct pain
relievers (Ashworth 8).
The use of physical therapy exercises to maintain muscle strength may be
appropriate for some patients. Whereas the use of braces, splints, or other
apparatus may maximize the ability to use the arm. Though counseling and
occupational changes, retraining or similar interventions might have to be
considered (Healthcentral 3). Another available form of treatment patients may
want to consider is acupuncture.
Acupuncture has been considered by many to be an alternative method of
healthcare, when other options have been exhausted. A 33-year-old, right-handed
Caucasian male awoke one morning in January, 1994, with a left-sided neck and
shoulder spasm causing severe pain, which was minimally relieved with a muscle
relaxant. The pain radiated from the armpit, near the arm and shoulder joint to the
end of the hand. December, 1992, excision of unstable skin and cross finger flap
reconstruction; left middle and ring fingers were cut off when he fell on a saw
blade. June, 1993, underwent surgery to relieve pressure on the nerves in the left
wrist and the left elbow. Acupuncture was the only method of relief for one
patient for pain in his left upper arm, after being appropriately treated with
medications and physical therapy for one year. Acupuncture treatment was chosen
for relief of all subjective and objective signs of left arm and shoulder girdle
brachial neuritis (Yang and Chang 1).
This patients schedule for this treatment was 27 sessions for three years using 30
gauge 1.5 inch needles for duration of 15 minutes. After the sessions were
completed this patient had immediate relief of the muscle spasm pain and there
was visible relaxation in the muscle themselves. The patients skin color return to
normal and had full range of motion in his left arm. The use of acupuncture as an
alternative therapy was successful in controlling the muscle spasms and pain of
brachial neuritis. The immediate response occurred just five minutes after
treatment sessions began. Acupuncture is an important treatment option for those
with this disorder (Yang and Chang 2-3). With this knowledge, acupuncture may
be subsequently used as alternative therapy for pain relief in similar patients.
While most physicians are used to thinking that every clinical problem has
a diagnosis and every diagnosis has a treatment, this is not the case for the
shoulder. Although most brachial neuritis conditions can be managed well, there
exists a few cases of brachial neuritis that are not amenable to definitive
treatment. In these situations the effectiveness of current treatment methods is
limited. The available resources can be directed to patient education, exercises,
and vocational rehabilitation. However a patient contracts brachial neuritis the
studies have shown that the outcome is generally good. The disease is not
progressive, and muscle strength in most patients begins to improve within the
first month after the onset of the symptoms. Depending on how serious the pain
and the amount of in the arms weakness, are good indicators of recovery in most
patients. The more severe the pain and weakness the longer the recovery time and
the greater chances of residual deficits (Quan 7). Although more is now known
about this condition, the underlying cause and effect continue to
elude physicians and researchers. For this reason, no specific treatment
recommendations can be offered to eliminate the cause. Current therapy is
primarily to treat the symptoms (Quan 7).
"The relationship of brachial neuritis to infections and inoculations
is unclear, but one possible conclusion based on these observations is that there is
an infectious etiology, possibly viral" (Quan 1-10). Though many physicians and
researchers are unclear as to what causes brachial neuritis. They all agree that it
is some type of damage or trauma done to the nerves in the brachial plexus
network. Though treatment is available for the symptoms of brachial neuritis.
Those patients who are diagnosed with brachial neuritis will have available
various forms of treatments such as medications and alternative treatments to
relieve the pain and discomfort brought on by the disorder.
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Haines, E. Duane. "Human Nervous System."
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Hamati-Haddad, Aline and Gerald M Fenichel. "Brachial Neuritis Following
Routine Childhood Immunization for Diphtheria, Tetanus, and Pertussis
(DTP): Report of Two Cases and Review of the Literature." Pediatrics,
99. 4 91997): 602. Academic Search Premiere. EBSCOhost.
5 Nov. 2002.
Miller, Jimmy D and Stephanie Pruitt, and Thomas McDonald. "Acute Brachial
Plexus Neuritis: An Uncommon Cause of Shoulder Pain". American
Academy of . Family Physician. Nov 2002. Nov 11, 2002
Quan Dianna. "Neuralgic Amyotrophy: Presentation of a Case and a Review of
the Syndrome". P&S Medical Review, Mar 1994: n.p.
Columbia-Presbyterian Medical Center. 11 Nov. 2002.
Reneer, Linda. Personal Interview. 18 Nov. 2002
Yang, Lynn W and Henry Chang. "Medical Acupuncture".
Medical Acupuncture Journal. 1998. 4.