Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Brachial Neuropathy


Related Terms

  • BN
  • Brachial Neuritis
  • Brachial Plexopathy
  • Brachial Plexus Dysfunction
  • Brachial Plexus Neuropathy
  • Neuralgic Amyotrophy
  • Parsonage-Turner Syndrome

Differential Diagnosis

Specialists

  • Anesthesiologist
  • Neurologist
  • Neurosurgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Radiologist

Comorbid Conditions

  • Autoimmune diseases (e.g., rheumatoid arthritis, lupus)
  • Cancer
  • Heroin, or other drug addiction
  • Obesity
  • Other injuries

Factors Influencing Duration

The length of disability may be increased by any of the following factors: the individual's need for full use of the involved arm, protracted pain with shoulder or arm motion, or residual muscle weakness. Conversely, the length of disability may be decreased if the individual is not in pain and has enough residual function in the unaffected arm for normal duties.

Medical Codes

ICD-9-CM:
353.0 - Brachial Plexus Lesions; Cervical Rib Syndrome; Costoclavicular Syndrome; Scalenus Anticus Syndrome; Thoracic Outlet Syndrome
723.4 - Brachial Neuritis or Radiculitis NOS; Cervical Radiculitis; Radicular Syndrome of Upper Limbs
953.4 - Injury to Nerve Roots and Spinal Plexus; Brachial Plexus Injury

Overview

Brachial neuritis (BN), or brachial neuropathy, is an inflammation of the nerves (neuritis) in the shoulder area. Nerve involvement in BN varies, but the lower motor neurons of a nerve complex in the neck and under the arm, called the brachial plexus, are primarily affected. Although the pain usually occurs in the right shoulder, 10% to 30% of the time it is bilateral (Ashworth). Pain is constant, intense, unrelieved by rest, and worsens at night. The intense phase of the pain may last from a few hours to several weeks, but some low-grade pain may continue for several months.

Whether or not the pain subsides, numbness and muscle weakness in the arm and shoulder usually follow within 3 to 10 days. The individual may experience shoulder paralysis and lose the use of that arm.

In some cases the exact cause may not be known (idiopathic brachial neuritis), but the condition may stem from an autoimmune reaction in which the body's own defenses are turned against the brachial plexus. Brachial neuropathy may follow traumatic injury to the brachial plexus, such as falling off a ladder, jerking the arm, and suffering gunshot and stab wounds. Other causes are a tumor pressing down on the nerves and radiation therapy for cancer. Brachial neuropathy occasionally follows surgery (when the individual was in the prone position), viral infections, cervical nerve blocks, or injections of serum, vaccines, or antibiotics. Acute brachial neuropathy (also known as acute brachial radiculitis and Parsonage-Turner syndrome) has been diagnosed in individuals with a history of previous infection and fever.

Rarely, BN occurs in an apparently healthy individual. For no apparent reason, the individual suddenly experiences severe shoulder pain, followed by shoulder paralysis and loss of use of an arm.

An inherited form of BN is linked to mutations in a specific gene (SEPT9 on chromosome 17q). This gene is involved in skeleton formation, but it is not known how mutations contribute to brachial neuropathy. Onset occurring during childhood is indicative of inherited brachial neuropathy.

Toxic etiologies for neuropathies such as brachial neuropathy are not as common as hereditary, metabolic, or inflammatory causes. Drug-related causes for toxic neuropathies are among the most common of toxic etiologies and may include antibiotics, diptheria or tetanus toxin, chloramphenicol, cisplatin or pyridoxine, or the use of recreational drugs. Toxic neuropathy associated with drug abuse may be difficult to confirm and is often discovered as a result of overdose emergencies. Neuropathy in drug abuse may develop days or weeks after the suspected abuse. Progressive neuropathies occurring as a result of exposure to industrial agents (e.g., chemical solvents and heavy metals, including acrylamide, arsenic, ethylene oxide, lead, mercury, perchloroethylene, styrene, toluene, and others) may produce symptoms slowly after limited or long-term exposure. In any suspected toxic neuropathy, the exact cause may not be uncovered (Rutchik).

Incidence and Prevalence: In the United States each year, there are approximately 1 to 2 cases per 100,000 person-years (Ashworth).
Although brachial neuropathy is reported to occur around the world, not all countries report incidence rates. Incidence is reported to be 3 cases per 100,000 population in the UK (Ashworth).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Males are 2 to 4 times more likely to have the condition than females, except with the inherited form, which affects males and females equally (Ashworth). Young to middle-aged adults are most commonly affected, although the condition can occur at any age (Ashworth).

Source: Medical Disability Advisor



Diagnosis

History: The individual with nontraumatic BN reports the sudden onset of severe pain in the muscles of the shoulder and frequently the arm and neck. Numbness and muscle weakness may also be mentioned. Onset may follow an infection, surgery, strenuous exercise, or injury. The individual may report having a recent injection or vaccination. Individuals may think they twisted their neck or pulled a muscle. A history of current or prior illness is obtained.

Physical exam: Patients most often seek care because of acute pain, and muscle pain is often evident on palpation. The affected arm may be hanging weakly or held by the individual's other arm. The muscles of the shoulder and upper arm (deltoid, biceps, triceps, and serratus anterior muscles) may be partly or almost totally paralyzed. The arm muscles may have decreased reflexes, and the arm and shoulder may have decreased sensation. Shortness of breath may be noted if the phrenic nerve is involved.

Tests: A shoulder x-ray may be done to rule out other shoulder pathology. The individual may be tested for intestinal parasites, which are a possible cause. Laboratory evaluation of health status may include a complete blood count (CBC), erythrocyte sedimentation rate, C-reactive protein, and antinuclear antibodies to rule out underlying systemic illness, especially connective tissue disease. The individual may also be tested for HIV.
Imaging studies and needle electromyography (EMG) are used to confirm this diagnosis. The time of onset of symptoms is very important since needle EMG evidence of denervation takes at least 10 days, and frequently 21 days, to develop following nerve injury. Thus, a negative needle EMG examination done within 10 days of the onset of symptoms should be repeated later. A 3-week interval is recommended in order to make certain that enough time has passed for needle EMG findings to be detectable. Brachial plexus neuropathy may have been diagnosed as an isolated inflamed nerve, suggesting local compression. EMG will determine whether this is correct or if the whole area is inflamed. Nerve conduction studies should be done to rule out peripheral neuropathy due to systemic diseases. MRI or CT may be done to investigate possible spine pathology, such as cervical radiculopathy.

Source: Medical Disability Advisor



Treatment

Brachial neuropathy is treated conservatively. While the pain is still present, pain relievers (analgesics) are given. The pain may be severe enough to require chronic narcotic therapy. A short course of high-dose oral steroids may be given. If brachial neuropathy developed during vigorous exercise, the individual is told to stop exercising the affected arm. The individual is generally advised to avoid constantly supporting the arm in a sling because of the risk of a "frozen shoulder." If pain and arm numbness continue for some weeks, physical therapy with range of motion exercises is recommended. In the unusual circumstance that the condition persists for over 2 years, the surgeon may consider nerve grafting or tendon transfers to improve movement.

Source: Medical Disability Advisor



Prognosis

Full functional recovery is expected in most individuals (80% within 2 years; 90% within 3 years), although recovery can be slow (Ashworth). Muscle numbness and decreased sensation usually last from 6 to 12 weeks. Some individuals continue to have residual feelings of weakness, and others may continue to have winging of the shoulder blade (scapula) and poor shoulder muscle control. Significant disability may persist in the affected limb in about 10% to 20% of individuals after 2 years (Ashworth). Generally, there is a less favorable prognosis for those with bilateral disease than for those afflicted in just one limb (bilateral brachial neuropathy is usually of the hereditary type) (Ashworth), and upper nerve trunk lesions resolve better than the lower nerve trunk lesions. The recurrence rate after recovery is 75% in the inherited form and between 5% and 26% in the idiopathic form (Ashworth).

Source: Medical Disability Advisor



Rehabilitation

Individuals who present with brachial neuropathy may require outpatient physical therapy at a frequency of 2 to 3 times a week for 4 to 8 weeks. The necessity of therapy depends on the degree of pain and weakness in the shoulder and upper arm.

The first goal of therapy is to control pain. This is accomplished through the initial use of a sling to provide support to the shoulder; however, a gradual return to movement is necessary to avoid shoulder contracture. Passive range of motion is employed as soon as tolerated. Individuals also learn to support the arm on a pillow when sitting in a chair. These techniques decrease the strain experienced by the inflamed nerves by decreasing the amount of traction forces to the shoulder that occur when the arm hangs in a dependent position. For individuals whose pain is not easily relieved, a transcutaneous electrical nerve stimulation (TENS) unit may be provided. This technique employs a small device that emits intermittent electrical impulses through electrodes placed on the shoulder and/or neck. These impulses block the perception of pain by the brain.

The second goal of therapy is to maintain range of motion at the neck, shoulder, and elbow. Individuals perform gentle, active range of motion exercises for the neck, shoulder, and arm in a pain-free range.

The third goal of therapy is the restoration of strength in the shoulder and elbow. Initially, the therapist teaches isometric strengthening, progressing to resistance exercises once the physician feels that further injury to the nerves will not be sustained.

For individuals with persistent shoulder or elbow weakness, neuromuscular electrical stimulation (NMES) may be appropriate. This technique uses a small device that emits an electrical impulse through electrodes placed on the weakened muscles. The impulse is strong enough to produce a muscle contraction and minimize muscle atrophy.

Source: Medical Disability Advisor



Complications

Brachial neuropathy typically results in rapid upper extremity muscular weakness and numbness even as pain resolves. Shoulder joint contracture can develop if immobility is not corrected. If pain persists despite treatment for brachial neuropathy, this may indicate an underlying disease or cause of injury that could require further workup. Severe breathing difficulty may occur if there is phrenic nerve involvement.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

The otherwise healthy individual will be limited by the pain, numbness, and weakness of his or her arm, with the result that lifting, carrying, and reaching overhead may be restricted. If recovery continues slowly over 1 to 3 years, medium to very heavy work will not be possible. If nerve damage is significant and permanent, the individual may be permanently limited to modified duty.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • What type of brachial neuropathy was diagnosed?
  • When was initial onset?
  • Is the condition unilateral or bilateral?
  • Is there a proven cause of diagnosis, or is the neuropathy considered idiopathic?
  • Has individual had recent infection and fever?
  • Has individual had any recent trauma to the arm or shoulder area? Radiation therapy? Gunshot or stab wound to the area?
  • Has individual recently had surgery or injections in the area?
  • Does individual use or have a history of using intravenous drugs?
  • Did individual have a sudden onset of severe aching in the shoulder? How long did it last?
  • Has individual developed muscle weakness in the same shoulder and arm? Numbness in the arm?
  • Are the reflexes decreased in the arm and/or shoulder? Is there paralysis in the shoulder or upper arm?
  • Was overall health status evaluated with appropriate laboratory tests?
  • Was shoulder x-ray performed to rule out other shoulder pathology?
  • Was an MRI or cervical spine and brachial plexus needle EMG done? Nerve conduction study?
  • Were any changes in abnormalities found in electrodiagnostic studies after onset, as compared to later studies?
  • Were conditions with similar symptoms ruled out?

Regarding treatment:

  • Has individual responded to conservative therapy?
  • Has pain been relieved with analgesics? Was chronic narcotic therapy given?
  • Did individual have a short course of oral steroids?
  • How long have symptoms persisted?
  • Is individual in physical therapy?
  • Was individual evaluated for appropriateness of treatment at a multidisciplinary pain and functional restoration center?

Regarding prognosis:

  • Did individual have full functional recovery or experience residual feelings of weakness?
  • Does individual have winging of the scapula and poor shoulder muscle control?
  • Is there evidence of shoulder contracture?
  • Is breathing compromised by phrenic nerve involvement?
  • Was recovery followed by recurrence of the condition?

Source: Medical Disability Advisor



References

Cited

Ashworth, Nigel L. "Brachial Neuritis." eMedicine. Eds. Benjamin M. Sucher, et al. 17 Nov. 2008. Medscape. 30 Jun. 2009 <http://emedicine.medscape.com/article/315811-overview>.

Rutchik, Jonathan S. "Toxic Neuropathy." eMedicine. Eds. Robert A. Hauser, et al. 24 Feb. 2009. Medscape. 15 Jul. 2009 <http://emedicine.medscape.com/article/1175276-overview>.

General

"Brachial Neuritis." Family Practice Notebook. 2008. 15 Jul. 2009 <http://www.fpnotebook.com/Ortho/Brachial/BrchlNrts.htm >.

Source: Medical Disability Advisor






Feedback
Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment. If you are seeking medical advice, please contact your physician. Thank you!
Send this comment to:
Sales Customer Support Content Development
 
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the author, editors, and publisher are not engaged in rendering medical, legal, accounting or other professional service. If medical, legal, or other expert assistance is required, the service of a competent professional should be sought. We are unable to respond to requests for advice. Any Sales inquiries should include an email address or other means of communication.