Bracial pexus stretch injury, while uncommon is quite painful and initially is undertreated. Specifically during the first 1 – 7 days in my experience. Often in the early stages it is misdiagnosed, often after repeated visits to doctors and various other clinicians alike, until the injury is finally indentified and appropriately treated. The purpose and goal of this blog is to reduce the pain and suffering for those individuals who are in the category of the initial phase of injury. The other is to get you to convey to the physician as accurately as possible the events leading up to the injury so you can get the proper treatment (again, as rapidly as possible).
The brachial plexus is a network (“web”) of nerves in the neck and upper back which eventually form the nerves of the arms. The nerve roots begin at the spine from the C4 –T1 levels. The contribution from the C4 level is generally very minimal. This network and the nerves which form and innervate the arms supply the motor (movement), sensory (feeling) and sympathetic-parasympathetic (an array of autonomic or automatic biological maintenance functions such as capillary vaso-dilatation and constriction) functions. While I could discuss this structure and the physiology in much greater detail, it would offer nothing of relevance to the individual seeking relief in the acute injury phase.
The injury is nearly always traumatic, although it could be the result of secondary pressure to the plexus or supplying nerve roots due to tumors, abscess or any space occupying lesion. The onset of pain, loss of sensation, paresis, paralysis or sympathetic problems would tend to be more gradual in these more rare instances and management is usually not an issue. The general mechanism of injury as initially stated is the category of stretch or traction. In the case of a motor vehicle accident (most often motorcycle) or gun shot and stab wounds, the identification of the injury and treatment is generally very smooth. Instances in which this injury is not accurately identified and treated are when it occurs in less “violent” circumstances. Some examples, but certainly not all inclusive: 1. Almost falling after loss of balance and during the righting (balance) reaction(s), the individual grasps and there is a sudden stretch or traction. 2. Arm is pushed or pulled backward, forward, upward in any of a number of daily activities which seems at the time to be “nothing of consequence”, yet pain, altered sensation, loss of strength are present and often severe. I once treated a patient, who likely was injured while surfing. 3. Relatively violent stretching of the neck may result in upper plexus injury. “Whip-lash injuries” sometimes involve injury to the C4 – C6 supply of the brachial complex. The most perplexing cases initially are those in which there was by the individual’s perspective, no real incident at all. For example, turning the head rapidly or being startled. Yet they generally had sudden onset(immediately or within a few hours) and severe symptoms of lower neck , shoulder and arm pain, loss or change of skin(cutaneous) sensation and weakness(paresis) and sometimes even complete paralysis of a muscle or muscle groups supplied by the plexus.
When the presentation is primarily sensory and weakness not readily apparent, the initial diagnosis often is that of: 1. Cervical pain, strain or sprain with radiculopathy (radiating arm pain). This is because these diagnoses are much more common and have a very similar presentation overall. The initial misdiagnosis is both a problem of the patient not remembering any “injury” and that of the clinician (any type) relying too heavily on “pattern diagnosis.” A thorough clinical exam and the resulting diagnosis (I will term a “process diagnosis”) even before any other tests such as radiological, labs, sonograms, etc. are preformed is essential. Before I leave this caveat, a process diagnosis means that all reasonable and probable possibilities are excluded and the diagnosis is the result of that which cannot be excluded by physical exam alone. This takes more time and physical testing, but ultimately is efficient as it prevents needless “educated guessing”, time and frustration (also expensive and unnecessary testing). It will generally mean faster resolution of pain and symptoms. The end result of a good physical exam may leave only one or two possibilities and effective treatment may begin right away. 2. The other common misdiagnosis associated with this diagnosis is Shoulder and RTC (rotator cuff) strain. This again is due to the common prevalence of these diagnoses vs. a brachial plexus injury.
Since the obvious mechanism of injury (violent stretch or traction) of the brachial plexus does not need address, I will now discuss the identification in brief, general terms and what to do to initially in regards to individual’s with or who suspect they may have a ”sub violent-traumatic” brachial plexus injury(nerve injury of the neck-and arm). One of the most significant factors with this injury is the unrelenting pain. There is no real comfortable position in the first days or even weeks. Pain killers including opiates and muscle relaxers often provide little or even no relief. NSAIDs which are at prescriptions strength provide no or little relief. So what does? Answer: steroidal medication such as prednisone will provide very good relief of pain within 1 – 2 days and in some individuals… within hours. Steroids “shutdown” the inflammatory processes, which are profoundly painful. This type of intervention must be considered when consulting your physician or in case you are consulting with any other type of health care provider. You will ultimately come to that conclusion as massage, touch, movement-exercise, modalities, chiropractic, acupuncture, you name it…doesn’t matter, will not work. Or if it does, is highly transient. Also, because a herniated disc also responds to this form of treatment and would have to be eliminated as a diagnosis anyway, so generally speaking, the benefit is high, risk is generally very low and the results are generally very good (Little, if any, downside and very good upside). This strategy will “buy you time” so to speak and allow a reasoned and measured process to occur with your doctor as opposed to a highly emotional and desperate process in which you will do anything.
Once the acute inflammation and pain have resolved and you can get comfortable (this includes ability to sleep), the next plan of action is to rest the arm.
This may mean up to 2 weeks and in some cases as long as 4 weeks using a sling to limit painful movement and activities. You should move the arm as soon as it is comfortable to do so. You should also use it for activities of daily living as comfort allows such as writing, eating, dressing, bathing, etc. Gradually you will move the joints of the arm and hand through all motions until it is restored. You will start to wean from use of the sling. Depending in the severity of the injury, this process could take as little as 1-2 weeks or as long as 3 months. If only muscle weakness is the result of the injury and not paralysis, then strengthening could be introduced as soon as the individual can tolerate lifting weight of 1 lb or more. Tolerate means no provocation of pain before, during or after the activity. If pain is provoked, then strengthening should be held for another couple of days or 1 week and then try again. At this stage a good and competent physical therapist or hand therapist (PT or OT with specific addition training with hand and UE injuries is advised). I always advocate (and always will) one on one treatment collaboration. Insist on working with the therapist (the same one) each and every time you formally are in treatment and do not except aides or assistants (that is a separate topic). A competent PT or hand therapist can guide you on the specific strengthening exercise and as your recovery advances, appropriate stretching. Initially all stretching is generally to be avoided as this is a stretch (traction) injury. Once good remodeling (healing) of the tissue occurs, stretching may well be indicated.
If there is paralysis or substantial weakness (paresis), then neuro-muscular electrical stimulation (NMES) may be indicated. The muscle or muscles which are weak or paralyzed would be targeted. Normally AC stimulation will be sufficient, but in some cases in which there is Wallerian degeneration (anteriograde) the use of direct current stimulation (DC) to the musculature is required until the peripheral nerve supply regenerates. Once movement, strengthening and NMES program is in place, formal follow up may be needed as much as twice a week or as little as once per month. There should always be a goal of long term self management and titration from formal therapist treatment to competent self treatment as recovery can last as long as years usually no more than 3 years at the most. Some form of splinting or bracing which is longer term may also be required to prevent deformities or further unintended injury as the individual recovers. Generally speaking the prognosis is very good for full recovery once it is identified and managed appropriately.
In summary, if you are experiencing unexplained neck, shoulder and arm pain which is severe, unrelenting, brachial plexus injury may be a factor. The first line of defense when comfort seems unattainable is to secure systemic steroid (short term trial) as soon as possible. Do not minimize your distress. Recognize that you are not diagnosing this type of injury (Brachail plexus stretch injury), only that you are actively collaborating with your physician in regards to “process diagnosis.” Conversely, systemic steroid use in the circumstance of unrelenting neck, shoulder and UE pain with recent onset and when there is clear tissue irritability and no position of comfort is reasonable under the supervision and care of a physician. This will buy you time (when steroid use is deemed appropriate) to address the coming definitive diagnosis.
Dr Michael J. Malawey, PT