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

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

Differential Diagnosis

Specialists

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

Comorbid Conditions

  • Autoimmune diseases
  • 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: age, 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

Acute brachial plexus neuritis is an uncommon disorder of unknown etiology that is easily confused with other neck and upper extremity abnormalities, such as cervical spondylosis and cervical radiculopathy. The brachial plexus is a bundle of nerves that travels from the spinal cord to the shoulder, arm, and hand. Brachial neuritis (BN) is a form of peripheral neuropathy, a disease typically characterized by pain or loss of function in the nerves that carry signals to and from the brain and spinal cord (the central nervous system) to and from other parts of the body (peripheral nerves).

Individuals with acute BN present with a characteristic pattern of acute or subacute onset of pain, followed by profound weakness of the upper arm and amyotrophic (muscle wasting) changes affecting the shoulder girdle and upper extremity (Miller).

Brachial neuritis is also commonly referred to as Parsonage-Turner syndrome or brachial plexus neuropathy. When acute BN occurs, the damage to the brachial nerves comes on suddenly and unexpectedly on its own, without being related to any other injury or physical condition; it is characterized by sharp, severe pain in the nerves of the brachial plexus, followed by weakness or numbness in the upper extremity. The cause of acute BN is unknown.

BN should be differentiated from brachial plexus injury, which is caused by a specific injury such as trauma or tumors. Examples include a knife laceration or in babies where a stretch injury to the brachial plexus occurs when they pass through the birth canal during labor. BN should also be differentiated from an inherited form of BN that 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 BN. Onset occurring during childhood is indicative of inherited BN.

Finally, the differential diagnosis for BN should include toxic etiologies that 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 (chloramphenicol), diptheria or tetanus toxin, 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 of BN per 100,000 person-years (Ashworth).

Although BN 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. Young to middle-aged adults are most commonly affected, although the condition can occur at any age (Ashworth). The inherited form of BN affects males and females equally (Ashworth).

For more information refer to "Disease and Injury Causation," pages 291–294.

Source: Medical Disability Advisor



Diagnosis

History: The individual with nontraumatic acute 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. Individuals may think they twisted their neck or pulled a muscle. A history of trauma is usually negative but the history for current or prior illness (flu-like) is common.

Although the pain usually occurs in the right shoulder, 10% to 30% of the time BN can be 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 follows within 3 to 10 days. The individual may experience shoulder paralysis and lose the use of that arm.

Physical exam: Individuals most often seek care because of acute pain and gradual onset of weakness. Muscle pain is often evident on palpation. The affected arm may be hanging weakly or held by the individual's other arm, as the individual prefers not to move the affected arm. The muscles of the shoulder and upper arm (deltoid, biceps, triceps, and serratus anterior) 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. Laboratory evaluation of health status may include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and antinuclear antibodies (ANA) to rule out underlying systemic illness, especially connective tissue disease. The individual may be tested for intestinal parasites, which are a possible cause. The individual may also be tested for HIV.

Imaging studies and needle electromyography (EMG) can be 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 neuropathy onset. 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. BN 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. Magnetic resonance imaging (MRI) or computed tomography (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. The individual is generally advised to avoid constantly supporting the arm in a sling because of the risk of adhesive capsulitis. 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.

If brachial neuropathy developed during vigorous exercise, the individual is told to stop exercising the affected arm. If the cause is from a stretch trauma, again observation is the first treatment choice. If the cause is trauma that results in laceration of the brachial plexus, then early surgery with repair has the best outcome.

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 BN 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 between 5% and 26% in the idiopathic form and 75% in the inherited form (Ashworth). Recovery from trauma that results in surgical repair depends on the time to repair, the number of nerves requiring repair, and the individual's age at the time of injury.

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.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistBrachial Neuropathy
Occupational or Physical TherapistUp to 20 visits within 12 weeks
Surgical
SpecialistBrachial Neuropathy
Occupational or Physical TherapistUp to 24 visits within 16 weeks

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 BN, 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.

Risk: Risk of reoccurrence is low. Recovery may take months, and residual loss of function is possible. Gradually increasing activities allows for return of function limited by tolerance.

Capacity: Recovery may take months, and function will depend on which muscles are weak and the degree of weakness, as well as job demands. Gradually increasing activities allows for return of function limited by tolerance. As strength returns, capacity should increase.

Tolerance: Tolerance is the limiting factor for return to work. As the pain decreases and strength and function increases, the tolerance will improve.

Accommodations: Most individuals will require a period of accommodation at work. Tolerance is the limiting factor for return to work. As the pain decrease and the function increases, the tolerance will improve.

Source: Medical Disability Advisor



Maximum Medical Improvement

504 days.

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? Muscle atrophy?
  • 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. Robert H. Meier, et al. 10 Dec. 2013. Medscape. 5 May 2014 <http://emedicine.medscape.com/article/315811-overview>.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Miller, Jimmy D. , Stephanie Pruitt, and Thomas J. McDonald. "Acute Brachial Plexus Neuritis: An Uncommon Cause of Shoulder Pain." American Family Physician 62 9 (2000): 2067-2072.

Rutchik, Jonathan S. "Toxic Neuropathy." eMedicine. Eds. Tarakad S. Ramachandran, et al. 30 Apr. 2014. Medscape. 5 May 2014 <http://emedicine.medscape.com/article/1175276-overview>.

General

Moses, Scott. "Brachial Neuritis." Family Practice Notebook. 18 Apr. 2014. 5 May 2014 <http://www.fpnotebook.com/legacy/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.