Brachial plexus injury mimicking a spinal-cord injury

Virtual Reality combined with Robotic facilitated movements for pain management and sensory stimulation of the upper limb following a Brachial Plexus injury: A case study

Brachial Plexus injuries are complex in nature caused in large by high impact traffic accidents which can lead to additional complications such as Complex Regional Pain Syndrome and even lead to amputation or the need for further surgical intervention. Treatment options to help repair the brachial plexus initially involve surgical intervention and post-surgery rehabilitation with medication to help with ongoing pain. Pain treatments used for these types of injuries are limited and differ in effectiveness. Paradigms utilising multimodal systems such as the one described in this paper based on virtual reality and robotics could yield results that are non-invasive and provide better rehabilitation outcomes for the sufferers. In this paper we present a single case study exploring whether Virtual Reality plus Haptic feedback have any practical potential for reducing upper limb pain and improving function in patients with brachial plexus injuries. The case study is presented with long standing complex combination of phantom limb and neuropathic pain. A decrease in perceived levels of pain was reported which amounts to a 50% reduction in pain from baseline and an improved range of motion. An examination of the sensory phantom map on the stump seems to indicate an early establishment of the thumb representation on the stump close to the area being stimulated with potential implications for prosthesis use.

REHABILITATION OF CHRONIC BRACHIAL PLEXUS NEUROPRAXIA AND LOSS OF CERVICAL EXTENSION IN A HIGH SCHOOL FOOTBALL PLAYER: A CASE REPORT

BACKGROUND AND PURPOSE

Brachial plexus neuropraxia (BPN), or "burners" and "stingers", affect 50-65% of football players, with a high rate of recurrence and the potential, in rare cases, for catastrophic injury. Existing literature on rehabilitation of these athletes is limited. The purpose of this case report is to describe the successful and comprehensive rehabilitation of a subject with recurrent brachial plexus neuropraxia using range of motion exercises, cervical and periscapular strengthening, stabilization exercises, and activity modification.

CASE DESCRIPTION

The subject was a 17-year-old high school linebacker with repeated BPN episodes. He presented with limited cervical extension, rounded shoulder posture, and weakness of the cervical and periscapular stabilizers, and was known to tackle using the crown of his helmet. Physical therapy intervention consisted of regaining full passive & active range of motion and strength in the neck, shoulders and periscapular region, including several novel stretches and exercises to address the subject's unique presentation. Dynamic stabilization, postural control, safe tackling form, and long-term maintenance exercises were also addressed to decrease risk of injury recurrence.

OUTCOMES

The subject regained full pain-free PROM, AROM, strength & stability throughout the upper body after ten treatment sessions over five weeks, and was able to return to full participation the next season with normal safe tackling form and no further episodes.

DISCUSSION

Despite the prevalence, chronic nature, and potentially devastating effects of BPN, little has been written regarding comprehensive rehabilitation of the condition. Regaining full upper body range of motion, strength, and dynamic stability, as well as normalizing tackling form, is essential to resolving BPN and preventing recurrence.

LEVEL OF EVIDENCE

Level 4, single case report.

Leptin is essential for microglial activation and neuropathic pain after preganglionic cervical root avulsion

AIMS

Preganglionic cervical root avulsion (PCRA) affects both the peripheral and central nervous systems and is often associated with neuropathic pain. Unlike peripheral nerve injuries (PNI), central lesions caused by disruption of cervical roots from the spinal cord following PCRA contribute to the generation of neuropathic pain. Leptin is involved in the development of neuropathic pain after PNI by affecting neurons. However, whether leptin is involved in microglial activation leading to neuropathic pain after PCRA is unknown.

MAIN METHODS

Preganglionic avulsion of the left 6^th-8^th cervical roots was performed in C57B/6J mice and leptin-deficient mice. A leptin antagonist or leptin was administered to C57B/6J mice and leptin-deficient mice after injury, respectively. The expression pattern of spinal and supraspinal microglia was examined by immunofluorescent staining. Von Frey filaments were used to test pain sensitivity.

KEY FINDINGS

Leptin is essential for the development of neuropathic pain after PCRA. Allodynia was absent in the leptin-deficient mice and the mice administered the leptin antagonist. We also found that leptin deficiency or the administration of its antagonist inhibited the development of microgliosis in the dorsal horn and brainstem. Furthermore, increase in the expression of CD86 and iNOS, and Wallerian degeneration were noted in the spinal cord. The administration of exogenous leptin to leptin-deficient mice reversed these effects.

SIGNIFICANCE

We concluded that leptin is involved in the proliferation and activation of microglia, which in turn enhances the development of neuropathic pain. Blocking the effects of leptin might be a target for the treatment of neuropathic pain after PCRA.

Neuropathic pain after brachial plexus avulsion--central and peripheral mechanisms

REVIEW

The pain that commonly occurs after brachial plexus avulsion poses an additional burden on the quality of life of patients already impaired by motor, sensory and autonomic deficits. Evidence-based treatments for the pain associated with brachial plexus avulsion are scarce, thus frequently leaving the condition refractory to treatment with the standard methods used to manage neuropathic pain. Unfortunately, little is known about the pathophysiology of brachial plexus avulsion. Available evidence indicates that besides primary nerve root injury, central lesions related to the abrupt disconnection of nerve roots from the spinal cord may play an important role in the genesis of neuropathic pain in these patients and may explain in part its refractoriness to treatment.

CONCLUSIONS

The understanding of both central and peripheral mechanisms that contribute to the development of pain is of major importance in order to propose more effective treatments for brachial plexus avulsion-related pain. This review focuses on the current understanding about the occurrence of neuropathic pain in these patients and the role played by peripheral and central mechanisms that provides insights into its treatment. Pain after brachial plexus avulsion involves both peripheral and central components; thereby it is characterized as a mixed (central and peripheral) neuropathic pain syndrome.

Penile erectile dysfunction after brachial plexus root avulsion injury in rats

Our previous studies have demonstrated that some male patients suffering from brachial plexus injury, particularly brachial plexus root avulsion, show erectile dysfunction to varying degrees. However, the underlying mechanism remains poorly understood. In this study, we evaluated the erectile function after establishing brachial plexus root avulsion models with or without spinal cord injury in rats. After these models were established, we administered apomorphine (via a subcutaneous injection in the neck) to observe changes in erectile function. Rats subjected to simple brachial plexus root avulsion or those subjected to brachial plexus root avulsion combined with spinal cord injury had significantly fewer erections than those subjected to the sham operation. Expression of neuronal nitric oxide synthase did not change in brachial plexus root avulsion rats. However, neuronal nitric oxide synthase expression was significantly decreased in brachial plexus root avulsion + spinal cord injury rats. These findings suggest that a decrease in neuronal nitric oxide synthase expression in the penis may play a role in erectile dysfunction caused by the combination of brachial plexus root avulsion and spinal cord injury.