Neoplastic Brachial Plexopathy Treatment & Management

Physical Therapy

Early passive range of motion (PROM) of the upper limb is appropriate to prevent contracture. If there is preserved volitional motor function, active-assistive range of motion (AAROM) and active range of motion (AROM) exercises may be instituted. Progressive resistance exercises, when tolerated, can help to maintain as much strength as possible. The physical therapist should instruct the patient in a home exercise program to incorporate self-directed range of motion (ROM) and strengthening activities whenever possible.

Physical therapy modalities also may be warranted for assisting in pain reduction in patients with NBP. Electrical modalities for pain control, such as transcutaneous electrical nerve stimulation (TENS) or interferential current, are reasonable but are considered to be a relative contraindication when applied directly over a malignant neoplasm. Edema control measures (eg, retrograde massage, elevation, compressive garments) may be considered. A sling or splint can help the patient maintain a comfortable position and protect the affected limb. A sling also can reduce edema, retard shoulder subluxation, and reduce additional traction on the brachial plexus.

Occupational Therapy

See the Physical Therapy section above. Completing a home safety evaluation for patients with NBP and their families is important. The home evaluation should include use of compensatory strategies and adaptive equipment to improve the patient's functional abilities. For example, a patient who can no longer perform bimanual skills may benefit from a device to help manipulate buttons in order to dress independently. The occupational therapist can work with the patient and maximize his/her capabilities in performing activities of daily living (ADL). The occupational therapist also can engage the patient in a sensory and motor re-education program if there is impaired function in the hand.

Speech Therapy

Though not directly related to plexopathies, metastatic neoplasm also may alter communication, swallowing, or cognitive function, requiring a speech therapy consultation.

Recreational Therapy

Recreational therapy can help to maintain the patient's interest and skills by incorporating leisure time activities into the rehabilitation program.

For more severe lesions, an interdisciplinary approach may be most effective, including prescription of physical, occupational, and recreational therapies. Coordination of therapies, consultants, complications, and medications is needed.

Treatment often is difficult and may be palliative; chemotherapy and radiation therapy (up to 50% of patients obtain significant pain relief) are used if the tumor is sensitive to them. In the aforementioned investigation by Kamenova and colleagues (see Causes), 22 of the study's patients received BP treatment, aimed specifically at the locoregional metastases, with radiation therapy (8 patients) or endocrine treatment or chemotherapy (14 patients) initially being employed.^[5] In 19 of these patients, partial or complete remission of pain and neurologic deficits, lasting a median period of 8 months, occurred.

As the disease progresses, adequate pain control is the most important goal as most patients succumb to neoplastic involvement of vital organs within a few years.

Several authorities advise referral of patients with NBP to surgeons with special expertise in treatment of NBP. Accurate diagnosis may prevent unnecessary surgery for carpal tunnel syndrome or thoracic outlet syndrome. Surgery usually is performed only for definite tissue diagnosis in secondary neoplasms. Primary tumors, like benign schwannomas, are encapsulated, permitting surgical excision without sacrificing adjacent nerves.

Most solitary neurofibromas can be resected without producing or increasing deficit, but this procedure is more difficult than excision of encapsulated tumors and usually requires magnification, intraoperative nerve action potential recording, and sometimes cable grafts. Some neurofibromas are "dumbbell tumors" that extend into the epidural space. Many benign tumors (including neurofibromas) can be removed without significant loss using surgical loupes or microscope and repetitive NAP recording. Plexiform neuromas are more difficult to remove because of extensive segments of nerve fiber involvement. Some elements may have to be sacrificed for pain control and to save the remainder of the plexus. In patients with severe intractable pain, dorsal rhizotomy, dorsal root entry zone surgery, or high contralateral percutaneous cordotomies can be considered. Amputation and other destructive procedures often are ineffective.

Most patients have a consulting oncologist, as well as an internist or family practitioner. Some patients may need an anesthesiologist or interventional physiatrist for injections, and some may have seen a neurologist, or less commonly, a neurosurgeon (for more drastic measures mentioned above). Consultation with a psychologist may be helpful in terms of emotional adjustment, pain control, and supportive counseling.

Paravertebral nerve blocks or other injection procedures may be indicated, depending on the location of the tumor(s). NBP often is widespread and is not amenable to application of selective blocks.