Brachial Neuritis

Brachial neuritis is a rare condition where there is inflammation of the group of nerves that control the shoulder, arm and hand, collectively known as the brachial plexus. It is difficult to diagnose accurately and causes severe shoulder pain followed by weakness. Symptoms tend to develop quickly without any obvious cause often starting at night and can be extremely unpleasant.

Brachial neuritis is also known as Brachial Plexopathy, Parsonage Turner Syndrome and Neuralgic Amyotrophy. 

Here we will look at what happens with brachial neuritis, the different types, what causes it, common symptoms, treatment options, prognosis and recovery process.

What Is Brachial Neuritis?

In brachial neuritis, there is inflammation of the brachial plexus which leads to severe pain and weakness

The brachial plexus is a network of intertwined nerves that originate from the root of the neck, pass across the chest over the first rib, through the arm pit (axilla) and down the arm. It is made up of the lower four cervical nerves (C5-8) and the uppermost thoracic nerve (T1). The brachial plexus controls movement and sensation in the shoulder, arm and hand.

Nerves carry signals from one part of the body for another. They carry messages from the brain telling muscles to contract or relax to produce movement as well as carrying sensory information regarding e.g. touch and temperature. With brachial neuritis, the brachial plexus becomes inflamed and the nerves don’t function normally leading to pain and weakness.

 There are two different types of brachial plexopathy:

1) Inherited Brachial Neuritis
This is an inherited condition where there is a mutation in the SEPT9 gene on chromosome 17q. It is an autosomal dominant condition. This means that a parent who carries the gene has a 50% chance of passing the faulty gene onto any child they have.

2) Idiopathic Brachial Neuritis
This is the most common type. The exact cause is unknown but it is thought to be due to an abnormality in the immune system which causes it to attack the nerve fibres of the brachial plexus resulting in inflammation.

Causes Of Brachial Plexopathy

Whilst the exact cause of brachial neuritis is unknown, the condition has been linked to:

a) Infection: Either viral e.g. upper respiratory tract infection or bacterial e.g. pneumonia
b) Surgery
c) Trauma: injury, not necessarily to the shoulder
d) Vaccinations: e.g. ‘flu jab and tetanus
e) Child birth
f) Systemic Illness e.g. lymphoma

Brachial plexopathy is a rare condition affecting between 1-3 people per 100,000 individuals per year.

Symptoms of Parsonage Turner Syndrome

Brachial neuritis symptoms usually come on rapidly, often starting at night. Pain tends to be the first symptom which then gives way to weakness/paralysis. Common symptoms include:

1) Pain: sudden, severe pain. People usually describe it as a sharp, stabbing or burning pain in the shoulder which may spread to the neck, arm and/or hand. It usually affects one shoulder (most commonly the right) but can affect both. The pain usually gets worse with any movement of the arm and at night. The pain tends to be constant i.e. present every second of every minute and only eases with strong painkillers

A winged scapula is often visible with brachial neuritis, caused by muscle wasting

2) Weakness: As the pain subsides (this may take days or weeks) muscle weakness/paralysis sets in. The muscle begins to waste (known as atrophy) which is often visible, such as a winging scapula, making it hard to move the arm. The weakness may be profound, but is usually temporary 

3) Numbness: If the sensory nerves are affected than your sensation is altered and you may notice some numbness, pins and needles and/or decreased sensation

4) Difficulty Breathing: In some cases (up to 5%) the diaphragm is affected which can lead to shortness of breath

5) Age Group: Can affect people at any age (including children which usually indicates the inherited version), but it is most common in young/middle-aged adults

6) Gender: Idiopathic brachial neuritis is more prevalent in males, approximately 3:1. Inherited brachial plexopathy affects males and females equally

Diagnosis

Brachial neuritis can be hard to diagnose and is often misdiagnosed as a neck problem. Your doctor will start by talking to you about your symptoms and will then examine you, looking particularly at your arm movements and muscle strength. They may also check your reflexes and sensation.

Your doctor will likely send you for imaging studies such as an MRI to rule out other conditions such as cervical radiculopathy and/or shoulder x-ray. Nerve conduction studies or EMG tests looking at the electrical activity of muscles may also be done to see if the nerves are functioning correctly. This helps to identify whether the weakness is due to a problem in the muscles themselves or a problem with the nerves that control the muscles, the latter of which may indicate parsonage turner syndrome.

Treatment Options

The initial goal with brachial neuritis is to reduce the pain. Once this has been achieved, you can start on a programme of physical therapy. 

1) Medication

Pain is usually severe and constant with brachial plexopathy and therefore strong painkillers are often required. These may include narcotic medication (opiates) such as hydrocodone and NSAIDS (non-steroidal anti-inflammatory drugs). Some doctors recommend using corticosteroids such as prednisolone to help reduce inflammation, but there is mixed evidence as to the efficacy of this. 

2) Physical Therapy

Physical therapy is an important part of rehab with brachial plexopathy to regain range of movement and strength.  Approved use www.hep2go.com

Initially, you will be advised to rest until your pain is under control, but then it is important to start physical therapy to address the associated muscle weakness and loss of movement. The aims of physical therapy are to:

a) Maintain and Improve Range of Movement: initially through passive exercises (when the arm is moved without the muscles having to work), either by someone else moving your arm, or you using your good arm to support the arm and lead the movement. Once pain is under control you can then move to active range of movement exercises (where you perform the movement yourself with the affected arm). Visit the rotator cuff exercises section for a range of exercises suitable for each stage

b) Regain Strength: Once the pain is controlled you can start rotator cuff strengthening exercises and scapular stability exercises to regain the strength and control around the shoulder

Your physical therapist may also use treatments such as ice packs, heat packs and/or TENS machines (transcutaneous electrical nerve stimulation) to help relieve pain.

3) Surgery

If symptoms fail to settle after a number of months, your doctor may recommend surgery. This usually consists of nerve grafts and/or tendon transfers (where healthy sections of nerves or tendons are taken from elsewhere in the body and used to repair the damaged nerves/tendons) to restore muscle function

Recovery & Prognosis

Recovery from brachial neuritis varies greatly between individuals but in most cases people make a full, or nearly full recovery. Usually, the pain settles within a few weeks, but it can take a number of months to regain full strength and range of motion at the shoulder. Around 80% of people who suffer from brachial plexopathy will make a full recovery within 2 years, with another 10% recovering further in the following year. In some cases, people will be left with persistent pain and/or weakness and reduced endurance in the shoulder muscles. Recovery time is often linked to how long the painful phase lasts (longer painful phase = longer recovery time).

Recovery from parsonage turner syndrome tends to take longer if symptoms are bilateral (in both arms). Recurrence is more common with inherited brachial neuritis (approximately 75% recurrence rate) than idiopathic brachial plexopathy (between 5-26% recurrence).

What Next?

If you are recovering from brachial neuritis, it is important to do exercises to regain strength and range of motion. Visit the rotator cuff exercises section for a whole range of exercises that can help. 

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