Treating 1 Case of Burning Neuralgia of the Brachial Plexus with Massage and Manipulation

（Xiaojun Xu）(Junming Zhou)

The patient was a 53-year-old male who came to our clinic in May of 2023 for what he described as “burning neuralgia of the right brachial plexus” which had been happening for 1.5 years. The patient had previously undergone multiple nerve transfer procedures at our hospital (transfer of the accessory nerve, intercostal nerve, and C7 stage I and II surgeries on the unaffected side) due to root avulsion of the brachial plexus, and he had gone through phased rehabilitation. About 3 months after surgery, the patient began to experience pain and numbness throughout the entirety of the right upper extremity with a burning sensation. This persisted for several hours every day and sometimes would be constant; the pain was prominent at night. The patient had taken anti-inflammatory and analgesic medications without any noticeable relief. Physical examination found that the right shoulder could only be abducted 60 degrees, elbow flexion strength had a grade of M2 (full ROM when not working against gravity), the fingers could be flexed slightly, and the intrinsic muscles of the hand were atrophied. A light touch on any part of the upper extremity could trigger pain and discomfort. The skin of the palm was dry with flaking skin and there was loss of protective sensation in the forefinger. On the Short-Form McGill Pain Questionnaire (SF-MPQ), the pain rating index (PRI) was 31 and the visual analogue scale (VAS) value was 8. The clinical diagnosis was burning neuralgia of the right brachial plexus.

This was followed by a comprehensive rehabilitation intervention consisting mainly of massage 3 times per week. After 3 months and 6 months, shoulder abduction and elbow flexion functions were assessed, along with an assessment of protective sensation in the forefinger and the Short-Form McGill Pain Questionnaire.

1. Massage manipulation techniques: rolling, 1-finger pushing, pressing, rubbing, grasping, and rocking methods. Acupuncture points on TCM channels and network vessels were selected, including: LI-4 (hé gǔ), LI-11 (qū chí), LI-10 (shǒu sān lǐ), LI-15 (jiān yú), GB-20 (fēng chí), cervical paravertebral points (jīng zhuī jiā jǐ), and painful (ā-shì) points. Procedure: with the patient in the seated position, the practitioner stood near the affected side and started with 1-finger pushing on GB-20 (fēng chí), cervical paravertebral points (jīng zhuī jiā jǐ), GB-21 (jiān jǐng), ST-12 (quē pén), LI-11 (qū chí), TW-5 (wài guān), and LI-4 (hé gǔ), 2 minutes per point. This was followed by rolling on the shoulder and upper extremity, and then pressing and rubbing on GB-20 (fēng chí), cervical paravertebral points (jīng zhuī jiā jǐ), GB-21 (jiān jǐng), LI-15 (jiān yú), SI-11 (tiān zōng), LI-11 (qū chí), and LI-10 (shǒu sān lǐ), 1 minute per point. The grasping method was used on the neck and shoulder joints as well as the upper extremity. Finally, the shoulder was rocked while holding the patient’s hand, passively moving the joints of the upper extremity within the permissible margin of safety. The treatment lasted about 20 to 30 minutes in total.

2.Transcutaneous electrical nerve stimulation: an electronic muscle stimulation device (TENS-21) was used. A heated positive electrode was placed on the back of the neck, while a negative electrode was placed on the forearm and palm. The intensity was adjusted to what the patient could bear. This was done for 30 minutes at a time, 2 times per day.

3.Sensory re-education: desensitization was performed by scraping or lightly tapping the hypersensitive areas of the upper extremity using different classes of materials, including cotton, towels, and sandpaper. This was done for 5 to 10 minutes at a time, 3 to 4 times per day. The intensity of the stimulation was gradually increased to help the patient adapt better. In addition, the patient was encouraged to do desensitization training at home by immersing his hands in granular substances and rubbing them together, starting with rice and then moving to red beans, soybeans, and finally peanuts, 3 to 4 times per day for 5 to 10 minutes at a time.

4.Psychological counseling: the patient was encouraged to actively use his affected hand and participate in more activities of daily living to distract himself from the pain. He was informed that even if this temporarily aggravated his symptoms, he should not give up easily. He was also given a frank estimate of the length of time needed for his recovery.

表 治療前後疼痛量表及功能評估

Table: Pain levels and functional assessments before and after treatment

Burning neuralgia of the brachial plexus refers to persistent pain symptoms occurring after damage to the brachial plexus, in which the extent of the pain goes beyond the area innervated by the injured nerves. At the same time, it is accompanied by a series of pain symptoms due to sympathetic dystrophy, which manifests as gripping pain with squeezing, pinching, and burning qualities. It is a chronic, stubborn form of neuropathic pain. In the long term, there may be motor dysfunction; dystrophies of body hair, nails, and skin; osteopenia; and even irreversible changes such as central pain syndrome^［1］. Pain that occurs after traumatic injury to the brachial plexus is a difficult problem to resolve. Although nerve transfers can improve the functions of the affected limb, for patients with chronic neuralgia, quality of life is significantly impacted. These patients may even develop affective symptoms such as anxiety, depression, or insomnia. Literature shows that patients in Asia rarely present with severe pain, while those in Europe and North America have a high chance of experiencing pain. Approximately 80% of patients with brachial plexus nerve injuries experience pain; for 20% of patients, this pain may be persistent^［2］. The patient discussed in this case had the following characteristics: ① The pain persisted for over a year after the injury (pain for 1.5 years, dystrophic stage) and it lasted several hours a day or could even be constant. ② There was indescribable burning pain. ③The range went beyond the innervation area of the injured nerves, conforming to the diagnosis.

The pathological mechanism that causes burning neuralgia of the brachial plexus is not yet clear, but it may be related to postganglionic neuromas. In patients with avulsion injuries who develop pain, it may be related to central nervous system mechanisms such as deafferentation or hyperactivation of the posterior horn of the spinal cord. At present, effective measures for controlling pain include psychological interventions (such as counseling, relaxation therapy, biofeedback therapy and support groups), physiotherapy rehabilitation (physical therapy and desensitization training), and medications (such as antidepressants and antiepileptic drugs). Massage has a long history of use in traditional Chinese medicine (TCM); as one of the external methods of treatment in TCM, it can free the channels and network vessels, quicken the blood and transform stasis, and quicken and disinhibit the joints. Based on the principle that “when there is free flow, there is no pain”, it promotes the dilation of capillaries, increases blood circulation, and enhances muscular blood circulation, thereby allowing injured tissues to be improved and repaired. It also speeds up blood and lymph circulation.

In this case, we provided rehabilitation therapy that consisted mainly of TCM massage manipulation. According to modern medicine, the mechanism by which massage suppresses pain can trigger corresponding changes in multiple neural circuits (such as sensorimotor and pain affective circuits), thereby relieving pain^［3］. Low-frequency electrical stimulation can increase the impulses in coarse afferent nerve fibers and suppress afferent impulses from fine nerve fibers that transmit pain signals. Sensory re-education reduces the pain response through habituation by constant exposure to stimuli from various types of materials. Stress management^［1］and psychological counseling, such as encouraging the patient to actively use the affected hand and guiding him to focus on normal life, intercept the mental interaction between pain or discomfort and attention^［5］. After 6 months, the range of motion of the upper extremity, shoulder, and elbow improved, and the burning neuralgia of the brachial plexus was significantly relieved.

References

1. Zorub DS, Nashold BSJ, Cook WA: Injury of the brachial plexus:a review with implications on the therapy of intractable pain. Surg Neurol 2:347-353, 1974.

2. Scott W. Wolfe, Robert N. Hotchkiss, William C. Pederson, et al. Greens operative hand surgery( Seventh edition). Elsevier, Inc.2017：1801.

3. 梁秉中，周俊明.實用骨科針灸推拿學［M].香港：香港中文大學中醫中藥研究所.2003：33-35

3. Liang Bingzhong, Zhou Junming. Shiyong guke zhenjiu tuina xue ［The study of practical orthopedic acupuncture, moxibustion, and massage］［M］. Hong Kong: Xianggang Zhongwen Daxue Zhongyi Zhongyao Yanjiusuo ［Institute of Chinese Medicine, The Chinese University of Hong Kong］. 2003: 33-35.

4. Crombez G,Viane I,Eccleston C,et al.Attention to pain and fear of pain in patients with chronic pain［J］.Journal of Behavioral Medicine.2013,36(4):371-378.

5. Neurobiological mechanisms of dialectical behavior therapy and Morita therapy, two psychotherapies inspired by Zen.J Neural Transm (Vienna) 2023 May 05.Pubmed ID 37145166.

Author information:

Xiaojun Xu is a female attending physician. Huashan Hospital Hand Surgery and Hand Function Rehabilitation Room.

Junming Zhou，

Associate Professor, Masters tutor，

Consultant of the Hand Surgery Rehabilitation Department of Huashan Hospital, Fudan University，

Tutor of the tutor group of Shanghai University of Traditional Chinese Medicine，

A member of the Standing Committee of the Orthopedic Rehabilitation Branch of the Shanghai Rehabilitation Medical Association，

Vice Chairman of the Work Injury Rehabilitation Committee of Shanghai Rehabilitation Medical Association.

推拿手法治療臂叢灼性神經痛1例體會

徐曉君 周俊明

患者 男，53歲，於2023年5 月因“右臂叢灼性神經痛1年半”來門診就診。患者曾於本院因“臂叢根性撕脫傷”在我院行多組神經移位術（副神經移位，肋間神經移位，健側C7I期及II期手術），曾階段性康復治療。

術後約3月開始出現右全上肢疼痛、麻木，伴燒灼感，每日持續數小時甚至無間歇時間，夜間痛明顯，曾服用解熱鎮痛藥，緩解不明顯。

門診查體：右肩外展60度，屈肘肌力M2，微屈指動作，手內肌萎縮。上肢任何部位的輕微觸碰即可引起疼痛不適，手掌部乾燥，脫屑，示指保護性知覺喪失。

簡易McGill疼痛問卷（SF-MPQ）中，疼痛評級指數（PRI）為31分，視覺模擬評分（VAS）為8分。

門診診斷：右臂叢灼性神經痛。

遂施行以推拿為主的綜合康復措施，一週3次，3月及6月後，行肩外展、屈肘功能評定、手指示指感覺評定及簡易McGill疼痛問卷。

1.推拿手法：滾、一指禪推、按、揉、拿、搖等法。

取中醫經絡穴位：合谷、曲池、手三里、肩髃、風池、頸椎夾脊、阿是穴等。

操作：患者坐位，醫者立於患側，先一指禪推風池、頸椎夾脊、肩井、缺盆、曲池、外關、合谷，每穴2分鐘，然後滾肩部及上肢，隨後按揉風池、頸椎夾脊、肩井、肩髃、天宗、曲池、手三里，每穴1分鐘，拿頸部、肩關節和上肢，最後，托手搖肩，在可允許的安全範圍內，被動運動上肢各關節。治療時間共20-30分鐘。

2.經皮神經電刺激：採用神經肌電促通儀（TENS-21），溫熱電極正極置於頸後部，負極置於前臂及腕掌部，強度大小以患者耐受為度。30min/次，2次/天。

3.感覺再教育：應用分級的材質 — 包括棉花、毛巾、砂紙等 — 划擦或輕拍上肢感覺過敏區域進行脫敏。每次5-10分鐘，3-4次/天。刺激強度呈逐步增加的過程，以使患者更好地適應。另外，鼓勵患者在家進行脫敏訓練：浸沒患手到顆粒中進行摩擦，按大米-赤豆-黃豆-花生米順序分級進行，3-4次/天，5-10分鐘/次。

4.心理疏導：鼓勵患者在生活中自主使用患手，多參與日常生活操作，以分散對疼痛注意力，並告知即使這些誘發症狀暫時性加劇，也不要輕易放棄，並坦誠告知恢復所需時間的預期值。

表 治療前後疼痛量表及功能評估

Table: Pain levels and functional assessments before and after treatment

臂叢灼性神經痛指在明確的臂叢損傷後，出現持續疼痛症狀，且疼痛範圍超過受損神經支配區，同時伴隨着一系列交感神經營養不良的疼痛症狀，表現為壓搾性、擠壓性以及燒灼樣的絞痛，是一種慢性頑固性神經病理性疼痛，長期可見運動功能紊亂，毛髮、指甲、皮膚的營養失調，骨量減少，甚至不可逆變化，包括中樞神經疼痛印跡^［1］。創傷性臂叢損傷後的疼痛是個非常棘手的問題，盡管神經移位術可以改善患肢的功能，但是慢性神經痛的患者，生活質量則受到很大的影響，甚至會出現焦慮、抑鬱、失眠等情感方面的症狀。文獻表明，亞洲患者較少出現嚴重的疼痛，而歐美的患者發生疼痛的概率很高。大約80%的臂叢神經損傷患者可以出現疼痛，20%的患者疼痛可能持續存在^［2］。本病例談論患者的特點①傷後疼痛持續一年以上（疼痛病程1.5年，營養障礙期），每日持續數小時甚至無間歇時間。②難言的灼性疼痛。③範圍超越損傷神經的支配區，遂符合該診斷。

臂叢灼性神經痛產生的病理機制還不是很清楚，可能與節後神經瘤有關，撕脫傷的患者產生疼痛，可能與傳入神經阻滯，脊髓後角過度活化的中樞機制有關。目前有效的控制疼痛包括心理干預（如咨詢、放鬆治療，生物反饋治療和支持小組），理療康復（物理治療和脫敏訓練）和藥物治療（抗抑鬱藥物、抗癲癇藥等）。推拿在中國傳統醫學中曆史悠久，它作為中醫的外治法之一，具有疏通經絡、活血化瘀、活利關節的效果，本着“通則不痛”的原則，促使毛細血管擴張，增加血液循環，使肌肉血液循環改善，損傷的組織可以得到改善和修復，可增快血液循環和淋巴回流。

本病例我們給予中醫傳統的推拿手法為主的康復治療。現代醫學認為，推拿鎮痛機制可引起多個神經環路（如感覺運動、疼痛情感）的相應變化，起到鎮痛作用^［3］。低頻電刺激可增加粗傳入神經縴維的沖動，抑制傳導痛覺的細神經縴維傳入沖動；感覺再教育，通過不斷的各種材料接觸刺激來習慣性的降低疼痛反應；精神壓力調控^［4］，心理疏導，鼓勵患者自主活動患手，引導其把注意力轉移到正常生活中去，阻斷疼痛不適與注意的精神交互^［5］。6个月後，上肢肩肘活動及手指活動度改善，臂叢灼性神經痛明顯緩解。

參考文獻

1. Zorub DS, Nashold BSJ, Cook WA: Injury of the brachial plexus:a review with implications on the therapy of intractable pain. Surg Neurol 2:347-353, 1974.

2. Scott W. Wolfe, Robert N. Hotchkiss, William C. Pederson, et al. Greens operative hand surgery( Seventh edition). Elsevier, Inc.2017：1801.

3. 梁秉中，周俊明.實用骨科針灸推拿學［M].香港：香港中文大學中醫中藥研究所.2003：33-35

3. Liang Bingzhong, Zhou Junming. Shiyong guke zhenjiu tuina xue ［The study of practical orthopedic acupuncture, moxibustion, and massage］［M］. Hong Kong: Xianggang Zhongwen Daxue Zhongyi Zhongyao Yanjiusuo ［Institute of Chinese Medicine, The Chinese University of Hong Kong］. 2003: 33-35.

4. Crombez G,Viane I,Eccleston C,et al.Attention to pain and fear of pain in patients with chronic pain［J］.Journal of Behavioral Medicine.2013,36(4):371-378.

5. Neurobiological mechanisms of dialectical behavior therapy and Morita therapy, two psychotherapies inspired by Zen.J Neural Transm (Vienna) 2023 May 05.Pubmed ID 37145166.

作者簡介:

徐曉君，女，主治醫師,復旦大學附屬華山醫院手外科手功能康復室。

周俊明,副教授,碩士生道師,

復旦大學附屬華山醫院手外科康復室顧問,

上海中醫藥大學道師團道師,

上海康復醫學會骨科康復分會常務委員,

上海康復醫學會工傷康復委員會副主委。