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.
Table: Pain levels and functional assessments before and after treatment
2-5指屈距掌紋（cm） Finger-to-palm distance for fingers 2-5 (cm)
8cm
7cm
5cm
示指感覺評定 （單絲測試） Assessment of forefinger sensation (monofilament test)
4.56-6.65（保護性感覺喪失）(loss of protective sensation)
3.84-4.31（保護性感覺减退）(reduced protective sensation)
3.84-4.31（保護性感覺减退）(reduced protective sensation)
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. Greens operative hand surgery( Seventh edition). Elsevier, Inc.2017：1801.
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, Masters 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.
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. Greens operative hand surgery( Seventh edition). Elsevier, Inc.2017：1801.
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.
