Massage Therapy and Brachial Plexus Injury

Research Review: Chang, C.-Y., Wu, Y.-T., Chen, L.-C., Chan, R.-C., Chang, S.-T., & Chiang, S.-L. (2014). Massage-Induced Brachial Plexus Injury. Physical Therapy.

Neck pain is one of the most common reasons for people to seek the care of a massage therapist. Whether it is whiplash from a motor vehicle accident or the chronic neck pain from sitting hunched over a desk all day, massage is frequently sought as a remedy for that all-too-common “pain in the neck.” However, it is crucial to remember that sometimes massage can produce adverse outcomes despite the best intentions of the therapist. This article is the first published report of brachial plexus injury sustained after a massage treatment.

Many people have neck pain that is effectively treated with massage, but we must remember there are a number of sensitive anatomical structures in cervical region and while injury is rare, certain massage approaches can cause injury to our client/patient. The authors of this study report on a case of brachial plexus injury that resulted from massage treatment of the neck region that was too vigorous.

The woman in this case came to the emergency room with symptoms of severe shoulder pain and numbness that began shortly after having received massage therapy treatment of the neck and shoulder region. The article reports that the massage treatment was performed in a chair, but does not elaborate on what specific techniques or methods were used that likely led to the injury.

The woman had sustained a previous injury to her shoulder region and had regularly been receiving massage as part of the treatment. However, she reported that on this most recent visit the treatment administered seemed to be deeper and more vigorous than usual. Within two days after the massage she was having increasing symptoms of pain, numbness, upper arm paralysis, and motor weakness affecting ulnar, median, and radial nerve branches in the upper extremity.

A series of testing procedures were run to rule out all likely possibilities as the cause of the current symptoms. EMG testing also verified damage to branches of the median, ulnar, and radial nerves. It appeared the most likely explanation for the onset of her symptoms was the previous massage treatment that had caused compressive damage to the brachial plexus.

The brachial plexus is a series of nerves that exit the cervical spine in the lower cervical region (Figure). There are three main cords of the brachial plexus, but they have different locations in the neck and upper extremity where some of these branches converge. There is a location in the cervical region called Erb’s point which is 2-3 cm above the clavicle where fibers of the C5 and C6 nerve roots converge. Convergence points of nerve branches are areas that are biomechanically vulnerable to outside forces. The authors of this paper speculate that adverse pressure was applied to the brachial plexus at Erb’s point and that was the cause of the current symptoms.

Nerve injury from massage therapy treatment is quite rare. So a question naturally arises of what the treatment was that caused the injury in this situation. The patient in this report had a previous shoulder and arm injury for which she had received surgery. The authors speculate that weakness and lack of development of a number of muscles in her neck and shoulder on the affected side made that area more vulnerable to injury because it was less protected.

The injury exacerbated by massage treatment eventually subsided after several weeks of conservative treatment. Most nerve injuries like this will heal on their own after a period of time, so it seems to have run the normal course of rehabilitation.

The key point to take away from this paper is remembering that massage treatment can and will produce client/patient injury in some cases. And, it is not always easy to know when you have performed a treatment that is too vigorous. It takes effective clinical reasoning to recognize that the shoulder and neck region on this affected side had compromised structural integrity and was therefore more vulnerable to the pressure applications in the region. The authors state:

Few complications associated with MT have been reported, and our case was a reminder that massage therapists need to carefully treat areas over nerves, vessels, and internal devices. Moreover, massage training should include sections on muscular anatomy and the nervous system, which will help avoid further nerve injury.

This last point is of key importance because many massage therapists have only received cursory attention in their anatomy courses to the complexities of the nervous system and how some of these superficial structures could be injured by pressure in the immediate region. I have repeatedly heard massage therapists say that their level of preparation to work with disorders of the nervous system was inadequate, and neural techniques are of particular interest in our training programs. That is one reason we have continued to focus significant attention on biomechanics, physiology and pathology of the peripheral nervous system in the clinical and orthopedic massage online continuing education courses.