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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 13  |  Issue : 2  |  Page : 116-120

Effectiveness of physiotherapy interventions in a case of postoperative onset brachial neuritis in 7 weeks pregnant woman


Department of Musculoskeletal Science, Ashok and Rita Patel Institute of Physiotherapy, CHARUSAT, Anand, Gujarat, India

Date of Submission24-Jul-2018
Date of Decision18-Mar-2019
Date of Acceptance21-May-2019
Date of Web Publication07-Oct-2019

Correspondence Address:
Dr. Hemal M Patel
Department of Musculoskeletal Science, Ashok and Rita Patel Institute of Physiotherapy, CHARUSAT Campus, Changa, Petlad, Anand - 388 421, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_26_18

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  Abstract 


Brachial neuritis (BN) is an uncommon condition characterized by the acute onset of excruciating unilateral shoulder pain followed by flaccid paralysis of the shoulder and parascapular muscles. Treatment is largely symptomatic in patients with BN, and opiate analgesia often is necessary in the initial period. The purpose of this case report is to describe the physiotherapy intervention strategies and report its effectiveness in the management of BN in a 28-year-old pregnant female who presented with the complaints of sharp pain over the left shoulder, arm, and scapula for 15 days. The condition was managed on the basis of clinical presentations with supervised and unsupervised physiotherapy intervention for 4 months, without any medications, as she denied taking any nonsteroidal antiinflammatory drug or steroid for the management of pain. The supervised physiotherapy interventions consisted of patient education, postural correction, exercise therapy, electrotherapy, and counseling for approximately 45–60 min a day for 5 days a week. The effectiveness of the physiotherapy intervention was followed for 4 months, and the symptom-specific outcome measures were reapplied. Physiotherapy interventions were found to have promising positive outcomes in the symptom management of the BN with increased patient satisfaction.

Keywords: Brachial neuritis, physical therapy, postoperative idiopathic brachial neuritis, pregnancy


How to cite this article:
Patel HM. Effectiveness of physiotherapy interventions in a case of postoperative onset brachial neuritis in 7 weeks pregnant woman. Physiother - J Indian Assoc Physiother 2019;13:116-20

How to cite this URL:
Patel HM. Effectiveness of physiotherapy interventions in a case of postoperative onset brachial neuritis in 7 weeks pregnant woman. Physiother - J Indian Assoc Physiother [serial online] 2019 [cited 2020 Jul 11];13:116-20. Available from: http://www.pjiap.org/text.asp?2019/13/2/116/268639




  Introduction Top


Brachial neuritis (B N) is an uncommon condition affecting approximately 1.64 cases/100,000 people between the age group of 20 and 60 years.[1],[2] Idiopathic Brachial neuritis is typically affects lower motor neurons of the brachial plexus.[1] Involvement of a single nerve or nerve branches can also occur.[1] Although symptomatology and physical examination findings may vary, the clinical course is generally unknown etiology characterized by acute onset of severe unilateral shoulder pain followed by flaccid paralysis of the shoulder and parascapular muscles.[3] This condition can be confused clinically with many common musculoskeletal conditions of the neck and shoulder that encountered daily in physiotherapy practice.[4]

Studies have proposed a viral or various infections as a potential etiological factor for this condition. Fifteen percent of cases have been reported as occurring postvaccinations. Other possible hypotheses include immune pathological inflammatory reaction precipitated by infection, surgery or systemic illness with concurrent injury to the involved nerves.[2] As per the current literature, available treatment for BN is medical treatment such as gabapentin, tramadol and an analgesic for the neuropathic pain. Intensive physiotherapy for rehabilitation to achieve strength, range of motion (ROM), and functional activities.[1],[2],[5] Corticosteroid use has not been proven to decrease recovery time.[6],[7],[8] Recovery is generally good. Improvement in strength begins from 1 month after symptom onset to <3 years. The majority of patients have substantial improvement within 3 years.[6]

Postoperative shoulder pain is an uncommon complaint in postgynecology procedures.[9] This case report is focused on a postpartum BN condition in an active female treated with only physical therapy and additional vitamin supplements where pain medicines are not prescribed considering the stage of pregnancy.


  Case Report Top


In our outpatient physiotherapy department, a 28-year-old pregnant woman presented with a sharp pain over the left shoulder, arm, and scapula after ovarian cysts surgery before 2 weeks. She described the pain as constant and burning in nature and scored it 9/10 on the visual analog scale (VAS). She complained that she could not perform shoulder movement in any direction and her sleep was disturbed due to extreme shoulder pain. She denied any history of trauma or any change in her activities. She was very cautious about the shoulder problem as it was in conjunction with her pregnancy.

She worked as a computer operator in a private company, and approximately 80% of her time was spent sitting using a computer. Apart from her work, she led an active lifestyle and used to perform her household chores as well. Since the time of pregnancy, she had maintained some physical activity in the form of walking for about 30 min daily and yoga.

At the 5th week of her pregnancy, she consulted the doctor for the pain in the lower abdomen. Routine pelvic examination and ultrasonography detected a left-sided ovarian cyst. Surgery for the cyst removal was suggested by the doctor. Based on the suggestion, it was planned and successfully performed under general anesthesia. Following the day of the surgery, she experienced pain over her left shoulder which she failed to report to her gynecologist during her hospital stay of 2 days, assuming that it may be due to her faulty sleep pattern. The pain got worsened since the time of her discharge, and she also noticed that numbness had developed in the lateral aspect of her left arm which prompted her to consult her doctor. She was then referred to an orthopedic surgeon who referred her to the neuro physician, and a clinical diagnosis of BN was made. A dose of prednisolone injection was given after the clinical diagnosis. The injections were prescribed for three more prednisolone injections, acetaminophen thrice daily, and a shoulder brace. She was also referred for physiotherapy treatment for the pain management and restoration of movement. However, she chose not to continue the pharmacological treatment of her pain due to concerns of adverse effects on the pregnancy and hence reported to the physiotherapy department for further management.

At the beginning of the 8th week of gestational period, she visited the physiotherapy rehabilitation with the complaint of pain in the left shoulder which was affecting her routine activities. On observation of the shoulder and trunk, the postural deviation was evident, forwarded head, rounded shoulder, and slouch posture. Wall push-up revealed obvious medial border winging of her left scapula with a medially rotated inferior angle. Mild muscle atrophy also found which was more evident in the left deltoid muscle. On palpation, there was spasm of the left upper trapezius muscle [Figure 1].
Figure 1: Winging of the left scapula in a patient with brachial neuritis

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Following, the physical examination of cervical motion, greater restriction of left active cervical rotation was reported as compare to right active cervical rotation but it did not produce any symptoms. All other movements were full and pain-free actively as well as on over pressure. Her daily pain pattern was proportionate with the activity level. Further physical examination revealed a flaccid, a reflexic paresis involving all muscle groups of the left upper extremity, more marked in the supraspinatus and infraspinatus, deltoid, and triceps. The presence of shoulder Sulcus sign was suggestive of deltoid weakness on the left side. Sensory examination of the upper limb showed mild hypoesthesia throughout the left upper extremity. No evidence was found for radiating pain.

The constant burning pain was subsided over the following week to an intermittent dull ache which she scored as 7/10 on the VAS. She also reported neck pain and stiffness which were severe in the morning hours. Muscle examination of the trapezius revealed relatively reduced strength and endurance of the middle and lower fibers on the left side. On focused examination of the shoulder, passive ROM was normal, but the end range was painful, and she could not perform active shoulder movement where she claimed it due to greater weakness. The other routine physical examination was within the normal limits. She did not undergo other investigations such as magnetic resonance imaging, electromyography, and nerve conduction velocity. The shoulder pain and related disability were assessed with shoulder pain and disability index (SPADI) before the physiotherapy interventions, and the score was 83.5% (pain 98% and disability 86%) [Table 1].
Table 1: Change in the scores of condition-specific outcome measures

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Physical therapy management

As per the history and finding in physical examination, physiotherapy rehabilitation program was designed for 5 days per week for initial 6 weeks, and the treatment frequency was changed to 3 days a week for remaining sessions. The primary aim of our treatment was to reduce the pain and spasm to prevent secondary complication related to musculoskeletal dysfunction due to adaptive changes and muscle atrophy and to boost psychologically. A second aim was to improve the strength of the shoulder and scapular muscles and to improve the functional activities of daily living (ADL) related to the upper limb. The supervised physiotherapy intervention consisted of patient education, exercise therapy, electrotherapy, and manual therapy, provided for 45–60 min. The unsupervised home exercise program (HEP) was designed based on his pain tolerance, improvement, and to maintain exercise adherence [Table 2].
Table 2: Physiotherapy interventions for idiopathic brachial neuritis patient

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The initial supervised treatment was focused on counseling and education regarding the condition and its prognosis, ergonomic, and good posture to facilitate exercise adherence. Physiotherapy intervention consisted of transcutaneous electrical stimulation and muscles energy techniques (MET) of the left upper trapezius muscle for pain and spasm and progressive resisted exercises for cervical and shoulder muscles. Rigid taping was used to reposition the scapula and the shoulder joint. Cognitive behavioral therapy (CBT) was introduced after the 3rd week of physiotherapy sessions (Given by expert). CBT was focused on modifying the coping skills of pain, imparting knowledge on pain perception, to facilitate the use of coping strategies, namely diverting attention, reinterpreting pain sensations, and ignoring sensations. During the entire rehabilitation phase, she chose not to undergo any pharmacological treatment for her pain because of her concerns of adverse effects on her pregnancy. However, she continued her folic acid and Vitamin D supplements and the antiemetic drugs as prescribed by the doctor. A HEP was designed and progressed as appropriate for better maintenance of the condition. She was provided with HEP manual to follow strictly. Exercise to the point of fatigue or pain or quality of the movement was some of the important instructions provided to her. HEP program was consisting of self-stretching of the upper trapezius muscle and active ROM exercise for shoulder girdle and cervical region. She was instructed to apply ice as and when required for pain and spasm.

To strengthen the shoulder girdle muscle, we started with pain-free isometric exercises of all shoulder girdle muscles with progressive doses. Once she was able to initiate voluntary shoulder movements, MET and isotonic exercises with resistance for the shoulder girdle muscles were given.

In the last 3 months (about 13 weeks), she had received 43 physiotherapy sessions with approximately 45–60 min a day. She was discharged with advice to resume routine activities. On discharge, she had minimal occasional pain (1/10 VAS), with remarkable reduction of the winging of scapula, forward head posture and satisfactory shoulder range of movement, and the SPADI score reduced to only 9% of disability. She had returned to her work and all other ADL, including cooking and driving without any difficulty as per her report. She was advised for a follow-up of once in 15 days at the time of the discharge. She came for two follow-up sessions, and at the end of that month, she was completely active as earlier.


  Discussion Top


This case report was intended to outline postoperative idiopathic BN (IBN) with its classic features, to provide an insight into physiotherapy management strategies, and to highlight its recovery in a patient who denied taking medication. This case was unique in many prospects. In our case, the condition started after her gynecological surgery, and during that time, she was in the 5th week of her gestational periods. She did not want to take any other medicine for pain relief and steroids during her pregnancy and hence, the symptom management was entirely relied on the physiotherapy strategies. At the time of discharge, she had already entered to the 2nd trimester of her pregnancy without any consequences from physiotherapy interventions.

There is limited literature until date describing the specific physiotherapy intervention which has shown to be effective in the treatment of IBN. In the acute stages, pain medication, especially opiate-based medication may be helpful in reducing pain. Some literature advocate the use of slings to immobilize the shoulder, reduce pain, and prevent stretching of weakened muscles. Physical therapy is advocated in few of the literature to maintain passive range, strengthen, and prevent complications.[10],[11] Corticosteroids have not shown any effectiveness in altering the course of the condition. Only a few evidence supports the use of modalities such as electrotherapy and acupuncture in the treatment of IBN.

Physical therapy is also an important adjunct in the treatment of BN to enhance ROM and strength of the shoulder girdle and function of the shoulder.[12] In our case, we used a range of electrotherapeutic treatment, exercise therapy, and CBT without the use of any pharmacological intervention, which resulted in early and satisfactory recovery. The mainstay of treatment, in this case, was physical means of intervention. Fortunately, this patient made a full recovery with no significant ongoing symptoms.


  Conclusion Top


Physiotherapy intervention in a combination of electrotherapeutic modalities, exercise therapy, cognitive behavior therapy, and unsupervised home-based exercise in the absence of pharmacological intervention gave promising results in symptom management in a case of IBN. There were no adverse effects of physiotherapy intervention during pregnancy in this case. Further trials may be carried out before generalizing the findings to other patients.



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hosey RG, Rodenberg RE. Brachial neuritis: An uncommon cause of shoulder pain. Orthopedics 2004;27:833-6.  Back to cited text no. 1
    
2.
Oliveira SG, Pombo EH, Batista PR, Cardoso IM, Rezende R. Parsonage-turner syndrome: Case report of a HIV-seropositive patient. Rev Bras Ortop 2010;45:456-9.  Back to cited text no. 2
    
3.
Burca ND. Brachial neuritis (Parsonnage–Turner syndrome) – A case study. Manual Ther 2009;14:567-71.  Back to cited text no. 3
    
4.
Mullins GM, O'Sullivan SS, Neligan A, Daly S, Galvin RJ, Sweeney BJ. Non-traumatic brachial plexopathies, clinical, radiological and neurophysiological findings from a tertiary centre. Clin Neurol Neurosurg 2007;109:661-6.  Back to cited text no. 4
    
5.
Terzİ R, Yılmaz Z. A brachial plexus lesion secondary to herpes zoster: A case report. Turk J Phys Med Rehab 2013;59:69-72.  Back to cited text no. 5
    
6.
McCarty EC, Tsairis P, Warren RF. Brachial neuritis. Clin Orthop Relat Res 1999;368:37-43.  Back to cited text no. 6
    
7.
Miller JD, Pruitt S, McDonald TJ. Acute brachial plexus neuritis: An uncommon cause of shoulder pain. Am Fam Physician 2000;62:2067-71.  Back to cited text no. 7
    
8.
Hershman EB. Brachial plexus injuries. Clin Sports Med 1990;9:311-29.  Back to cited text no. 8
    
9.
Rix GD, Rothman EH, Robinson AW. Idiopathic neuralgic amyotrophy: An illustrative case report. J Manipulative Physiol Ther 2006;29:52-9.  Back to cited text no. 9
    
10.
Miller JD, Pruitt S, McDonald TJ. Acute brachial plexus neuritis: An uncommon cause of shoulder pain. Am Fam Physician 2000;62:2067-72.  Back to cited text no. 10
    
11.
Fibuch EE, Mertz J, Geller B. Postoperative onset of idiopathic brachial neuritis. Anesthesiology 1996;84:455-8.  Back to cited text no. 11
    
12.
Wade J, Taylor T. Postpartum idiopathic brachial neuritis in a sport medicine physician. J Brachial Plex Peripher Nerve Inj 2015;10:e50-2.  Back to cited text no. 12
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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