Brachial Plexopathy

Brachial plexopathy is a type of peripheral neuropathy which refers to damage to a single nerve or a group of nerves. As mentioned earlier, the brachial plexus is an area where nerves from the spinal cord branch into the arm nerves. The nerves of the brachial plexus then run from your lower neck through your upper shoulders. Therefore, brachial plexus injuries can occur in many ways, such as the types below:

Brachial plexus rupture

In a brachial plexus rupture, a forceful stretch causes the nerve to tear, either partially or completely. This is a more serious injury than other brachial plexus injuries. Ruptures can cause weakness in the shoulder, arm, or hand and can even make certain muscles unusable. Depending on the severity and location of the rupture, these injuries can often be repaired with surgery.

Brachial Neuritis

Also known as Parsonage-Turner syndrome, this is a progressive disorder of the nerves of the brachial plexus. This syndrome causes sudden, severe shoulder and upper arm pain and progresses from pain to weakness, muscle loss, and even loss of sensation. This syndrome typically affects the shoulder and arm, however, it can affect the legs and diaphragm.

Brachial plexus neuroma

Brachial plexus neuroma is scar tissue that forms as the brachial plexus attempts to repair itself. This scar tissue can result in a painful knot on one of the nerves. This only occurs when you are going through surgery.

Brachial plexus avulsion

A brachial plexus avulsion happens when the root of the nerve is fully separated from the spinal cord. This injury is normally caused by trauma, such as a vehicle or motorbike accident. Because it is difficult and usually impossible to reattach the root to the spinal cord, avulsions can lead to permanent weakness, paralysis, and loss of feeling.

Symptoms depend on where along the length of the brachial plexus the injuries occur and how severe they are. Therefore, the common symptoms linked to brachial plexopathy include:

• Inability to control or move the shoulder, arm, wrist, or hand.
• An arm that hangs (limping).
• Numbness or loss of feeling in the hand or arm.
• Burning, stinging or severe, and sudden pain in the shoulder or arm.

In severe cases, brachial plexopathy injuries result from motor vehicle accidents, especially motorbike accidents. Severe injury can also be the result of a gunshot or knife wound or a fall from a great height.

Furthermore, an infant may sustain brachial plexus injury during difficult childbirth. This type of injury can occur if the baby’s neck is stretched to one side. After your child experiences a brachial plexopathy injury, he or she may develop either of the following conditions below:

• Erb’s palsy – This condition often affects the upper portion of the brachial plexus. A child usually has weakening involving the muscles of the shoulder and biceps.
• Klumpke’s palsy – Klumpke’s palsy involves the lower roots of the brachial plexus. It usually affects the muscles of the hand, although almost never occurs in babies or children.
• Horner’s syndrome – This condition can lead a child to have ptosis (drooping eyelid), miosis (smaller pupil of the eye), and anhydrosis (diminished sweat production in part of the face).
• Total plexus involvement – Total plexus involvement affects all five nerves of the brachial plexus. Your children may also be unable to move their shoulder, arm, or hand.

Such longer-term complications that are caused by brachial plexopathy are quite numerous and include:

• Reduced stamina and balance
• Discrepancies in limb length
• Impaired bone growth
• Joint dysfunction

Muscle atrophy, which is the shrinking of muscle tissue, could also result from brachial plexus injuries because of reduced muscle movement and disruption to the nerve supply. With sufficient nerve supply, however, muscle mass may increase with exercise.

Also, a reduced supply of nerves also has an impact on regular muscle movement, even without muscle atrophy. Brachial plexopathy alters the movement and biomechanics of the body, limiting dexterity, range of motion, and the structure and formation of the joints in the affected limb. The result is abnormal movement, and wear patterns could develop over the years, increasing the risk of osteoarthritis.

Another known complication that plays a role in brachial plexopathy is scoliosis. This is a rare condition that can also occur due to this type of injury. Oftentimes, scoliosis is so severe that surgery is required.

If your doctor suspects symptoms linked to brachial plexopathy, he or she will perform a thorough physical examination to determine the cause of the injury and rule out other conditions alongside. Your doctor will examine all nerve groups controlled by the brachial plexus to identify the specific location of the nerve injury and its severity.

The pattern by which nerves from the brachial plexus manage various muscles of the arm and hand will assist your doctor in identifying potential sites of nerve injury. After a physical exam has been done, your doctor may order additional imaging tests to get a clearer view of the condition that is affecting your brachial plexus, such as:

X-rays

This imaging test creates a clear image of dense structures, like bones. X-rays of the neck, chest, shoulder, and arm are precisely taken to rule out associated fractures.

Computed Tomography (CT) scan

This test is usually performed at least 3-4 weeks after the injury to allow any potential blood clots in the area of the nerve root to dissolve.

Electrodiagnostic studies

These tests measure nerve conduction and muscle signals. They are important evaluation tools due to the higher success rate of confirming the diagnosis. It is used to locate the nerve injury, characterize its severity, and assess the rate of nerve recovery. This test is normally done 3-4 weeks after the injury, as it allows any nerve degeneration that may occur to become detectable.

After a diagnosis has been done, physiotherapy may be further advised. A physiotherapist will design a treatment program specific to your condition and goals. These are performed to prevent or reduce joint contractures, maintain, or improve muscle strength, and increase daily activities to encourage participation. Therefore, treatments include:

Passive and active stretching

Your physiotherapist will assist you in performing gentle stretches to increase joint flexibility (range of motion) and prevent or delay contractures (tightening) in the arm.

Improving your strength

Your therapist will teach you exercises and perform activities to maintain or increase arm strength. He or she will identify certain tasks that promote strength. As your brachial plexus heals, your physiotherapist will identify higher-demanding activities that will continue to strengthen your arm and hand.

Modalities

Your physiotherapist might use a variety of modalities (intervention techniques) to improve muscle function and movement. Electrical stimulation is sometimes applied to gently stimulate the nerve signal to the muscle. Flexible tape can be applied over specific muscle areas to help guide proper muscle movement or promote relaxation. Constraint-induced movement therapy (CIMT) may also be applied to the non-affected arm to gently limit its use and encourage the use of the affected arm.

Supporting equipment

Weakness of the shoulder muscles can lead to the unsupported weight of the arm slowly pulling down on the shoulder causing partial dislocation (subluxation). Therefore, your physiotherapist will advise you to wear a custom or off-the-shelf brace (orthosis) to avoid contracture of the fingers, thumb, wrist, or elbow. Some orthoses are to be used only at nighttime to keep the limb in a certain position or they can be used during the day to help complete tasks.

Below are some examples of exercises for you to try. The exercises may be recommended to reduce symptoms linked to brachial plexopathy:

Triceps kickback

Hold a dumbbell in your hand while kneeling on a bench with the opposite leg. Next, bend forward and place your arm on the bench to support your body weight. Lift your affected arm until your upper arm is parallel to the ground with your elbow bent and hand pointed toward the ground. Keeping your elbow by your side, straighten your arm until your elbow is straight, hold this position for 2-3 seconds, then repeat 3-4 times a day.

Rubber band stretches

Wrap a rubber band around your fingers. Then, spread your fingers apart and hold for 2-3 seconds. Slowly bring them back together and repeat 10 times a day.

Lateral raises

Stand up straight and squeeze your shoulder blades together. Holding a dumbbell in your hand, turn your thumb toward the ceiling. Next, lift your arm out to the side until it is parallel to the ground. Finally, hold for 2-3 seconds, then slowly lower back down before repeating this method 3-4 times a day.

Most cases of brachial plexopathy require some type of treatment to help manage the initial pain levels, such as one of a combination of the following:

• Pain medications – such as non-steroidal anti-inflammatory drugs (NSAIDs) or nerve pain medications may be recommended on a short-term basis for severe pain.
• Rest – Specifically avoiding movements of the affected arm and shoulder may avoid worsening the pain.
• Ice/heat application – Applying ice may help reduce inflammation, while applying heat later in the process may help facilitate blood flow to the painful area and loosen stiff muscles.
• TENS unit – This device sends electrical signals via wires to electrodes that are attached to the skin on sticky pads. The ultimate goal is for the electrical signals to interfere with and reduce the pain signals being sent to the brain.