John is a 33 year old male who works for Canada Post. He is an avid motorcyclist and enjoys working out at the gym on a daily basis. He lives with his wife in a condo in Griffintown on the 15th floor. In their free time, John and his wife enjoy going rock climbing together. They are planning on starting a family and hope to have two children.
During a recent motorcycle ride, John got into an accident while trying to avoid a child running across the street. After hospitalization, the doctors told him that he had sustained a brachial plexus avulsion on his right side. Specifically, all his nerve roots in that region have been torn from the spinal cord. He constantly complains about a burning type of pain in his right upper extremity (shoulder, arm and hand) ever since the accident. He also has a loss of motor control and numbness in that area.
John is right handed and his job involves lifting heavy boxes. He worries about the impact this injury will have on his daily living as well as the future he has planned with his wife.
1. Neurological aspects (Etiology) – Emilie
A brachial plexus injury occurs when the nerves sending signals from your spinal cord to your shoulder, arm and hand are stretched, compressed, or torn (Mayo Clinic Staff, 2017). The most serious brachial plexus injury is known as a brachial plexus avulsion and occurs when the nerve roots are torn from the spinal cord (Mayo Clinic Staff, 2017). In a brachial plexus avulsion, the preganglionic axons of sensory afferents and motor efferents are torn between the dorsal root ganglion and the spinal cord (Teixeira et al., 2015). This leads to sensory and motor deficits. Due to the location of the tear, the somatosensory system is injured in these patients leading to neuropathic pain affecting touch, pain and temperature sensitivity. In many cases, the proximal location to the spinal cord also has effects on the central nervous system leading to central sensitization. This leads to hyperalgesia, allodynia and secondary hyperalgesia that extends beyond the affected area (Teixeira et al., 2015).
2. Epidemiological aspects – Emilie
Brachial plexus avulsion can occur in individuals of any age. However, young males between the ages of 15 and 25 are more often affected by this type of injury (Foster, 2015). These types of injuries tend to occur when the shoulder is forced down and the neck is stretched away from the shoulder (Mayo Clinic Staff, 2017). Individuals participating in contact sports, in particular football and wrestling, or involved in high speed accidents have an increased risk of injury (Mayo Clinic Staff, 2017). Around 70% of injuries were caused by motor vehicle accidents, and, of that, 70% were due to motorcycles or bicycle accidents (Foster, 2015). Other possible instances of injury are due to tumors putting pressure on the nerves and during difficult births where the infant remains wedged in the birthing canal or the labor is prolonged (Mayo Clinic Staff, 2017).
3. Clinical aspects (Signs & symptoms) – Kelly
a. What are distinctive clinical signs and symptoms associated with this medical condition? What are the principal factors needed for a differential diagnosis?
(Ex: hemiplegia, ataxia, tremor, loss of short term memory)
There are many signs and symptoms associated with brachial plexus injuries, but they depend on the severity of the injury. Less severe brachial plexus injuries result from the nerves getting stretched or compressed usually after engaging in strenuous sports or physical activities (Mayo Clinic Staff, 2017; Birth Injury Guide, 2017). This leads to stingers or burners that are characterized by a burning sensation all along the arm. Individuals with less severe brachial plexus injury can also experience numbness and weakness in the arm. Usually, these symptoms are temporary as they do not last for so long (Mayo Clinic Staff, 2017). More severe brachial plexus injuries result from a rupture in the nerve or when the nerve root is torn from the spinal cord (avulsion) caused by a trauma (Mayo Clinic Staff, 2017). This type of injury leads to paralysis of muscles in the arm, shoulder or hand resulting in loss or lack of movement in the arm. Sensation in the arm, shoulder or hand can also be completely lost (Mayo Clinic Staff, 2017). Some patients experience a specific type of pain associated with severe brachial plexus injuries called avulsion pain. This type of pain is characterized by burning or crushing at the location of the nerve rupture (Birth Injury Guide, 2017). Other impairments that can be associated with this condition include Erb’s palsy only affecting C5, C6, C7 spinal nerves resulting in paralysis or weakness of the arm, Global Palsy affecting all the nerves of the brachial plexus (C5-T1) leading to paralysis of the shoulder, arm and hand and loss of sensation along the arm, or Horner’s Syndrome characterized by pupil constriction or drooping of the eye due to a nerve damage affecting the eye (Cincinnati Children’s, 2015). To be able to successfully diagnose a brachial plexus injury, clinicians start with an initial history taking and move on to clinical examinations such as muscle charting, sensory charting, checking radial pulse for subclavian artery injury or checking for Honer’s sign (Thatte et al., 2013). Additional testing such as imaging techniques can be used including X-rays, CTs, MRIs and electrodiagnostic studies which measure nerve conduction (NCS) and muscle signal (EMG) (Bishop et al., 2015; AASH, 2017).
References I used:
–>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644778/ → reference done
–>http://www.mayoclinic.org/diseases-conditions/brachial-plexus-injury/symptoms-causes/syc-20350235 → ref done
–>http://www.birthinjuryguide.org/brachial-plexus-injury/symptoms/
_surgery/conditions/brachial_plexus_injury_bpi.html → ref done
–>https://www.cincinnatichildrens.org/health/b/brachial-plexus → ref done
–>http://orthoinfo.aaos.org/topic.cfm?topic=A00678 → ref done
–>https://www.assh.org/handcare/hand-arm-injuries/Brachial-Plexus-Injury → ref done
b. Are other impairments associated with this condition?
(Ex: hydrocephalus and cognitive impairments are often associated with spina bifida)
4. Psychosocial aspects – Alisha & Ginny
What are the functional implications of this medical condition? i.e. What are the activity restrictions and participation limitations to be encountered in the individual’s daily activities?
(Ex: Is there an increased probability of falls? What are the limitations for the person?)
John will face physical, psychological and social challenges due to his right side brachial plexus avulsion. Because of the limited mobility in his right arm, he will have physical difficulties with the ADLs such as dressing, eating and bathing, therefore restricting him in taking care of himself (Manusco et al., 2015) . He will also be unable to perform as well in his job since it is physically demanding. Even simple activities like sleeping will be a challenge for him since he is in constant pain. In terms of participation limitations, he may have trouble participating in activities he enjoys, such as motorcycling, weight lifting, and rock climbing. As a result, he may prevent himself from participating in social activities or events with friends and family which could lead him to feel bored and unsatisfied with his life (Manusco et al., 2015).This decrease in physical activity, lack of adequate sleep and activity participation could be detrimental to his health and psychological well-being. The worry that he may be incapable to equally participate as a parent to his future children, in terms of providing enough financial support, or playing with them, might decrease his self-esteem potentially leading to mental health problems such as anxiety and depression. In essence, this injury may diminish his overall quality of life.
Mancuso, C. A., Lee, S. K., Dy, C. J., Landers, Z. A., Model, Z., & Wolfe, S. W. (2015). Expectations and limitations due to brachial plexus injury: a qualitative study. Hand (New York, N.Y.), 10(4), 741–749. http://doi.org/10.1007/s11552-015-9761-z
https://www.christopherreeve.org/living-with-paralysis/health/causes-of-paralysis/brachial-plexus-injury
http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/peripheral_nerve_surgery/conditions/brachial_plexus_injury_bpi.html
https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-015-0329-x (only about avulsion + good image)
http://orthoinfo.aaos.org/topic.cfm?topic=A00678 (good images for powerpoint of brachial plexus)
5. What are the most common medical treatments currently in use for this condition? – Mathilde (Ex: rTPA, Ritalin, surgery, rehabilitation, diet restrictions, etc.)
For each of these medical treatments consider:
The clinical signs and symptoms alleviated by this treatment.
How the treatment acts on the clinical signs and symptoms.
The positive and negative impacts of the medical, surgical and/or rehabilitation treatment on functional outcomes of the individual.
Treatments chosen for brachial plexus injuries highly depend on the severity, type and location of the injury as well as on the health of the patient (Mayo Clinic Staff, 2017). When performed soon after the injury, surgery can be chosen as a treatment option. Past nine months, it is better avoiding it as the risks are too important compared to the potential benefits (Sakellariou et al., 2014). Unfortunately, as for any type of surgery, complications need to be taken in consideration (e.g. infections, blood clots, heart attacks, stroke, chronic pain, death, etc.). Furthermore, surgeries won’t necessary restore the patient’s upper limb functions and require a long recovery (Bishop et al., 2015).
A variety of surgeries can be performed to help patients with brachial plexus injuries.
Nerve repair (neurolysis) consists of reattaching two nerve edges together, often after a knife cut (Bishop et al., 2015/Sakellariou et al., 2014). Nerve grafting consists of taking a nerve from somewhere else in the body (often from sural nerve) and to put it between the two edges of the severed nerve, which restores nerve signals, guides nerve regrowth and consequently brings back functions (Mayo Clinic Staff, 2017; Bishop et al., 2015). Nerve transfer (neurotisation) is often performed after preganglionic root injuries (Sakellariou et al., 2014). It consists of taking a branch of a surrounding nerve (e.g. ulnar or median nerves) and connecting it to the distal part of the nerve injured at its root (Mayo Clinic Staff, 2017). Transfers being close to the target muscles, the limb can then receive electrical inputs again and rapidly retrieve its functions (Bhandari & Maurya, 2014). Unfortunately, this surgery technique provides greater results for the upper plexus than the lower, which limits hand functions retrieval (Sakellariou et al., 2014). Patient with complete root avulsion can undergo brachial plexus reimplantation surgery, in which “ nerve grafts [are] stitched to avulsed roots [… and] implanted into the spinal cord […]†(Kachramanoglou et al., 2017). Although the patient has sensorimotor gains, few sensory functions are retrieved compared to motor (Bhandari & Maurya, 2014). Future treatments focus on nerve growth stimulation and synthetic nerve grafts and root avulsion repair in spinal marrow (Sakellariou et al., 2014). Other surgery techniques and advances include tendon and free functioning muscle transfers, nerve conduits and use of fibrin glue (Bhandari & Maurya, 2014).
Pain is a major complication of brachial plexus injuries that can be managed through medications, which need to be personalised to the patient’s other medication and health conditions to limit possible interactions. Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids can first be given (Sakellariou et al., 2014). Unfortunately, NSAIDs (e.g. aspirin, naproxen) can impair the liver, the kidneys, the cardiovascular system and the gastrointestinal system (e.g. upset stomach, ulcers, hemorrhages) (Ong et al., 2007). Opioids (e.g. morphine, oxycodone, fentanyl) can have constipation, drowsiness and mood swings as sides effects and can lead to tolerance, dependence and addiction (CAMH, 2010). Therefore, for long-term treatment of neuropathic pain, other medication classes are favoured: antiepileptic drugs (e.g. gabapentin, carbamazepine) or antidepressants (e.g. amitriptyline) (Sakellariou et al., 2014). They respectively may induce side effects such as drowsiness, tiredness and blurred vision (Schachter et al., 2014), or constipation, diarrhea, nausea, weight gain and diminished sexual drive (Drugs.com, 2017). Many patients dealing with brachial plexus root avulsion will require a dorsal root entry zone (DREZ) lesioning in the spinal cord to reduce their pain (Siqueira & Martins, 2011). This last resort method consists of surgically creating a lesion in the DREZ, which then prevents sensory inputs such as pain to enter the spinal cord and reach the brain (UPMC, 2017; John Hopkins Medicine, n.d.).
Rehabilitation treatments can also help patients. Physical therapists can recommend exercises and stretching techniques to maintain the range of motion (ROM) and diminish joint stiffness, muscle atrophy and contractures of the affected arm, while occupational therapists can help patients doing ADLs with the other arm. They can both help with assistive devices to support the affected arm (e.g. splints, braces) or diminish swelling and contractures (e.g. compression apparel) (Bishop et al., 2015).
Furthermore, mental health problems of patients (e.g. anxiety, depression, sleeping problems,) can be approached by other health professionals such as psychologist or psychiatrists. Social workers can also deal with patient’s work and employment. All in all, an interprofessional collaboration and support from family and friends are required for the patient’s well-being, surgery recovery and overall rehabilitation (Bishop et al., 2015).