CONSERVATIVE MANAGEMENT OF BRACHIORADIAL PRURITUS IN A 47-YEAR-OLD FEMALE: A CASE REPORT

Introduction

Brachioradial pruritus (BRP) is a rather rare condition that presents to offices and is problematic to diagnose.¹ Patients typically present to an office with symptoms of itching, burning, tingling, and/or stinging sensations in the upper extremities usually following the pattern of the C5 and C6 dermatome.^1,2 The symptoms may be unilateral or bilateral; however, most cases will present with bilateral symptoms.^1,2 The specific cause of BRP has not been clearly defined but theories have suggested it can be due to cervical radiculopathy secondary to cervical spine pathology and/or exacerbated by overexposure to ultraviolet radiation (UV).^1–3 BRP is more common in women than men and typically will be seen in women with lighter skin types.^1,2 The average age of the patient with BRP will be 59, nevertheless, cases have been documented from ages of 12-84.^1,2,4

A clinician may have a challenging time determining which course of treatment would be most beneficial for a patient that is diagnosed with BRP. Conservative treatment such as cervical manipulation, acupuncture, and physiotherapy has been successful in treating BRP.¹ At times medication, topical ointments, pain management, and surgery have been necessary in attempts to alleviate the symptoms. We present this case to demonstrate that the combination of manual cervical manipulation and soft tissue therapy was able to alleviate the symptoms related to BRP.

Case Report

A 47-year-old female presented with chief complaints of itching and neck stiffness. The patient stated that her itching began approximately 3 weeks prior to the first visit after she went on a cruise. The patient initially thought the itching was due to the sake she had consumed while on the cruise that day. Itching and the visual appearance of hives were the preliminary symptoms, with the hives noted as mild the following morning and then resolving later that day. However, the itching remained present on the base of her skull, back of her neck, ears, dorsilateral forearms, and the inner part of her thighs the itching occurred 2-3 times per day and lasted for 20-30 minutes. The patient sought chiropractic care because she believed her itching was due to a pinched nerve in her neck. She reported that upon rolling her neck, she would hear a crunching noise, which started around the same time as the itching. Topical creams were attempted to minimize the itching but were unsuccessful.

The patient had received previous chiropractic care for cervicogenic headaches, low back pain, patellofemoral disorder of her left knee, left side sciatica, and left piriformis syndrome. All prior complaints have been resolved.

A full examination was performed including general observation, palpation, range of motion testing, orthopedic exam, sensory testing, muscle strength, reflexes, and a cranial nerve exam. Upon observation of her skull, neck, ears, and forearms, no hives were present. There was palpable hypertonicity on the right suboccipitals, left rhomboids, and left upper trapezius muscles. Range of motion revealed decreased right rotation, while all other ranges of motion were normal. Orthopedic exams performed were cervical distraction, shoulder depression, O’Donoghue’s, foraminal compression, and L’hermittes, which were all negative. Sensory testing was unremarkable. Reflex testing revealed decreased left triceps scoring a 1; all other reflexes were scored a 2. Muscle strength testing was unremarkable. The patient’s thoracic spine and low back were also examined, and all testing was unremarkable. Orthopedic tests for thoracic spine were Adams’ forward bend, Schepelmann’s and Kemp’s. Orthopedic testing in the lower back consisted of iliac compression, iliac distraction, sacral thrust, thigh thrust, Kemp’s and slump test. All muscle strength, sensory, and reflexes for lower extremities were unremarkable.

After the exam, we determined that she would be treated for neck pain due to muscle spasms of her bilateral suboccipitals, rhomboids and upper trapezius, using soft tissue therapy and chiropractic adjustments. She was advised to track the episodes of itching and report during the next visit. A care plan was created with a frequency of 2 visits per week for 6 weeks for a total of 12 visits. The patient signed an informed consent and was given outcome assessment tools (OATs) to complete. OATS used were The Patient Specific Functional Scale, Yellow Flag form, and the Pain Disability Questionnaire. The patient’s goals on The Patient Specific Functional Scale were to improve her neck stiffness from 3/10 to 7/10 by the end of her 6 weeks of care. The Yellow flag form score was a 30 and she answered no for everything on the Pain disability Questionnaire. At the time, The Palmer Florida Clinic had no explanation for her complaint of itching. During her initial visit, she was adjusted at C3 using the Supine Diversified technique, C6 with Activator, T5-T7 using the Diversified Anterior technique, and her sacrum using Thompson drop technique. Manual release therapy (MRT) was performed on her left rhomboids to address muscle hypertonicity.

Following the patient’s initial visit, research was performed to further investigate the complaint of itching. Upon review of the literature, a condition known as brachioradial pruritus (BRP) was found that matched the patient’s complaint of itching on her dorsolateral forearms and the base of her neck. A diagnostic test for BRP is called the “ice pack test” in which placing an ice pack on the skin when itching occurs will cause the itching to cease.

The patient returned for her 2^nd treatment and reported no itching since her last appointment. Recommendations included using an ice pack if the itching were to return. During her 2^nd visit, the patient was adjusted at C2 using supine Diversified technique, C6 with the Activator instrument, T6 using double transverse technique and the left ilium using Thompson Drop technique. MRT was performed on her left levator scapulae and rhomboids. We discussed with the patient that the itching could be caused by a condition noted as brachioradial pruritus and not a reaction to the sake. We suggested that if the patient experienced an episode of itching again to complete the “ice pack test.” The patient returned 2 days later for her 3rd visit. She reported the itching returned over the weekend on the lateral forearms. However, after placement of an ice pack, symptoms resolved. The positive “ice pack test” led to the diagnosis of brachioradial pruritus due to potential overexposure to the sun while on the cruise. The patient was adjusted at C2 and C6 using the supine Diversified technique, T5 with Diversified anterior technique and the right ilium using Thompson Drop technique. A hot pack was placed on her thoracic spine and MRT was performed on her left rhomboid muscle to reduce hypertonicity. Our patient left the visit with a decrease in the symptoms overall and was advised to return in several days for a follow-up appointment.

No itching was reported after her 3rd visit. She attended 5 more appointments over the course of her 6-week care plan completing 8/12 recommended visits. During those 5 visits, C2 and C6 were adjusted, and soft tissue therapy was performed to address muscle hypertonicity. The patient’s itching was fully resolved; however, neck stiffness never fully resolved potentially due to non-compliance with recommended treatment visits.

Discussion

Overall, brachioradial pruritus (BRP) is a rather uncommon neurologic condition, consisting of symptoms including unremitting itching, tingling or paresthesia, burning or stinging pain.¹ Unfortunately, the etiology of BRP continues to be unclear, although 2 mechanisms are commonly considered. One possible cause of BRP is related to cervical radiculopathy, which can be a result of several pathologies, such as intervertebral disc herniations and degenerative disc disease, as well as foraminal and central stenosis.^2,3,5 A possible reason is that these conditions can result in dorsal nerve root compression and inflammation, and can be a recurrent or constant generator for symptomatology.^2,6 The association between BRP and cervical spinal changes has been noted on radiographs between the levels of C3 to C7, with the most common incidence to be at the C5 and C6 levels, and the degeneration and stenosis noted at these levels was associated with the dermatomal distribution for BRP.¹ BRP has been demonstrated by electroneuromyography to be present with dermatomal distribution between C5-C8, many with radicular involvement at the same spinal level.⁷

Alternatively, some authors have proposed that BRP pathogenesis may be attributed to sun-induced cutaneous injury to the peripheral nerves, given that BRP may be exacerbated by exposure to ultraviolet (UV) light and warmth.^1–3,8–10 BRP was once formerly known as solar pruritus, with an increased prevalence seen in patients that resided in warmer tropical and subtropical climates, such as Florida, and remissions noted during cooler periods.^1,3,5 Thus, our data would support a potential role for solar ultraviolet radiation in the pathogenesis of BRP. Excessive exposure to UV light can result in damage to and a reduction in a subset of histamine-sensitive C-fibers which are responsible for the transmission of pruritus.² At a microscopic level, BRP includes actinic elastosis and a decreased number of epidermal and dermal nerve fibers, which mimic those findings seen with exposure to ultraviolet rays and phototherapy treatment.^2,8 Solar radiation may exacerbate pruritus by inducing the spontaneous firing of damaged peripheral nerve fibers.⁸ As such, one treatment approach for BRP is the avoidance of UV light, which has been shown to be beneficial for some patients in reducing symptoms, especially those with seasonal variations.^1,8,9 This consists of the use of sunscreen and long-sleeved UV-protective clothing when engaging in outdoor activities or in the warmer summer months.¹

Brachioradial pruritus remains poorly understood due to the paucity of literature that exists. Consequently, the clinician may have difficulty determining the best course of treatment. Currently, medical management options include medications, interventional pain management, and surgery have been utilized, in addition to conservative management approaches.¹ However, there are no current Food and Drug Administration (FDA)-approved treatment options for neuropathic itch, with most options being based on expert recommendations, off-label usage, and theoretical advice.⁸ First-line options include topical medications that have shown limited success, such as Capsaicin, which is the most commonly prescribed. (1-3,8.9) Second-line treatment includes neuromodulators, antidepressants, and anticonvulsants for moderate to severe cases.^8,9 Given the possibility of sedation and other side effects, the risks and benefits of these medications should be considered in those who may be particularly sensitive, such as the elderly.⁹ For patients with refractory BRP, no surgical procedures have been shown to be superior.¹¹ Nguyen et al. present a case of BRP initially managed with an anterior cervical discectomy and fusion (ACDF) followed by an ACDF revision four months later due to the return of mild symptoms that had gradually worsened and updated radiographs, which revealed migration of the cage at 6- and 12-week post operative appointments.¹² A complete resolution of symptoms was then reported at 6-, 12-, and 24-month follow-up visits.¹² In addition, Hernandez et al. describe two cases of BRP that began after trauma and were successfully treated with ACDF.¹¹ Surgery should be considered in those with cervical spine disease that have failed conservative treatment.^11–13 However, future research is warranted to better understand the effectiveness and long-term outcomes of surgical intervention.¹³ Due to the role of exposure to ultraviolet radiation in BRP, multimodal approaches to symptom relief may be warranted and will most likely provide better outcomes.¹¹

Conservative interventions have been shown to be effective in treating BRP, including full resolution of symptoms.⁴ Manual therapy approaches to care including chiropractic manipulative therapy (CMT), traction, flexion distraction, soft tissue manipulation, and neurodynamic mobilization have been shown in the literature to be effective means of care, with varying technique approaches.^1,2,4,14 Other methods including massage and physical therapy, acupuncture, TENS, and ice have also been shown to improve symptomatology, in particularly itching intensity and pain..^1,2,4,14,15 The mechanism for which many of these therapies offer benefit hinges on the improvement of joint dysfunction and reduction in both nerve root compression and inflammation, leading to a reduction, centralization or resolution of symptoms.^2,9,16 When conservative measures have been exhausted, the levels of surgical intervention that the evidence shows resolution of BRP correlate to other studied findings for levels between C5-C8, as well as significant findings that have been found to corelate radiographically between C3 and C7.^1,7,11,12 Though radiographically noted changes may be evident in some cases, MRI, CT, and electromyography studies may be also helpful in the diagnosis and subsequent care of BRP. ^17,18

Limitations

This is a single patient case report with a successful outcome using manipulation of the cervical spine and manual therapy. One of the potential causes of BRP is cervical spine disease. The patient had no prior imaging of her cervical spine; however, the patient had met the criteria for demographics and overexposure to UV radiation. Other cases using conservative care management have been successful treating BRP. This case report may provide further evidence that advanced studies should be conducted to conclude proper evidence-based management practices for patients with BRP.

Conclusion

A clear cause of BRP remains unclear; however, research is leading toward UV radiation and cervical spine disease. This case report highlights the successful treatment of a patient diagnosed with BRP utilizing cervical manipulation in combination with manual therapy to resolve the symptoms. Further research should be established to determine evidence-based treatment guidelines for the management of BRP.