eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy

Neoplastic Brachial Plexopathy: Treatment & Medication

Author: Mark A Wren, MD, MPH, Medical Director, Department of Physical Medicine and Rehabilitation, HealthSouth Rehabilitation Hospital of Texarkana
Contributor Information and Disclosures

Updated: Jan 19, 2010

Treatment

Rehabilitation Program

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.

Medical Issues/Complications

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.

Surgical Intervention

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.

Consultations

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.

Other Treatment

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.

Medication

No medications are specific for this diagnostic entity. Typical analgesic and adjunct analgesic agents may be worthwhile in managing neoplastic plexopathy.

Opioid analgesics (eg, long-acting oxycodone or fentanyl) are associated with fewer concerns about tolerance and dependency than many other opiates. A ceiling effect is also absent with these agents, while use of combination agents like hydrocodone/acetaminophen may be limited by maximum dose of acetaminophen allowable (4 g/d). Opiates may be effective at acceptable doses and often are tried first. For more mild symptoms, topical analgesics should be tried.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be helpful and usually are tried in conjunction with other agents.

Adjunct agents such as tricyclic antidepressants (eg, nortriptyline, amitriptyline) or other antidepressants (eg, sertraline, venlafaxine), anticonvulsants (Lyrica, gabapentin, Tegretol), and, less commonly, antiarrhythmics (eg, mexiletine) may be used for control of neuropathic pain.

Opioid analgesic agents

Should be used early in the disease. As in most painful conditions, begin with low potency medications at low doses and taper to desired response.


Hydrocodone and acetaminophen (Vicodin, Lortab, Norcet)

Drug combination indicated for moderate to severe pain.

Adult

1-2 tab PO q4-6h prn; not to exceed 4 g/d acetaminophen

Pediatric

Not established

Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants

Documented hypersensitivity, high altitude cerebral edema (HACE), or elevated intracranial pressure (ICP)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction


Oxycodone (OxyContin)

Indicated for the relief of moderate to severe pain.

Adult

10 mg PO bid

Pediatric

Not established

Phenothiazines may antagonize analgesic effects; MAOIs, general anesthesia, CNS depressants, and tricyclic antidepressants may increase toxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D if used for prolonged periods or in high doses; caution in COPD, emphysema, and renal insufficiency


Fentanyl (Duragesic)

Potent opioid analgesic with much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia.
Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.

Adult

25 mcg/h transdermal system q72h
After initial dose, subsequent doses should not be titrated more frequently than q3h or q6h thereafter
When using transdermal dosage form, most patients are controlled with 72 h dosing intervals; some patients require dosing intervals of 48 h

Pediatric

Not established

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects of fentanyl when both drugs are used concurrently

Documented hypersensitivity; hypotension or potentially compromised airway where it would be difficult to establish rapid airway control

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation; do not use in opioid naive patients

Corticosteroids

Can be helpful since inflammation may be part of the pathophysiology of the pain of NBP, as previously mentioned.


Prednisone (Deltasone, Orasone, Meticorten)

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

Adult

60 mg/d PO; taper quickly over 5-12 d

Pediatric

0.05-2 mg/kg/d PO; taper quickly over 5-12 d

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity, GI disease, viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

Cyclooxygenase-2 (COX-2) inhibitors

Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.


Celecoxib (Celebrex)

Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek lowest dose for each patient.

Adult

100 mg PO qd

Pediatric

Not established

Coadministration with fluconazole may cause increase plasma concentrations because of inhibition of celecoxib metabolism; coadministration with rifampin may decrease plasma concentrations

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D in third trimester; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction or in abnormal liver lab results

Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions. Inexpensive older NSAIDs like ibuprofen or naproxen may be considered; however, COX-2 inhibitors with their lower GI toxicity are often first-line agents.


Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Adult

200 mg PO qid

Pediatric

Not established

Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D in third trimester; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy


Naproxen (Naprosyn, Naprelan, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.

Adult

250 mg PO bid

Pediatric

Not established

Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D in third trimester; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Tricyclic antidepressants

A complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission and block the active reuptake of norepinephrine and serotonin.


Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain. Used as adjunct therapy.

Adult

10-100 mg/d PO hs

Pediatric

Not established

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Documented hypersensitivity; patient has taken MAOIs in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, and urinary retention

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in elderly patients


Nortriptyline (Pamelor, Aventyl HCl)

Used as adjunct therapy. Has demonstrated effectiveness in the treatment of chronic pain. Used as adjunct agent.
By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, this drug increases the synaptic concentration of these neurotransmitters in the CNS.
Pharmacodynamic effects such as the desensitization of adenyl cyclase and down-regulation of beta-adrenergic receptors and serotonin receptors also appear to play a role in its mechanisms of action.

Adult

10 mg PO tid/qid up to 150 mg/d

Pediatric

25-35 kg: 10-20 mg/d PO
35-54 kg: 25-35 mg/d PO

Cimetidine may increase levels when used concurrently; may increase PT in patients stabilized with warfarin

Documented hypersensitivity; narrow-angle glaucoma; do not administer to patients who have taken MAOIs in past 14 d

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Cimetidine may increase nortriptyline levels when used concurrently; nortriptyline may increase PT in patients stabilized with warfarin

Anticonvulsants

Use of certain antiepileptic drugs, such as the GABA analogue Neurontin (gabapentin), has proven helpful in some cases of neuropathic pain. Have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. The multifactorial mechanism of analgesia could include improved sleep, altered perception of pain, and increase in pain threshold. Rarely should these drugs be used in treatment of acute pain, since a few weeks may be required for them to become effective.


Carbamazepine (Tegretol)

May reduce polysynaptic responses and block post-tetanic potentiation. Used as adjunct therapy.

Adult

100 mg PO bid on first day and increase by 200 mg/d with 100-mg increments PO q12h prn; not to exceed 1200 mg/d

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Serum levels may increase significantly within 30 days of danazol coadministration (avoid whenever possible); do not coadminister with MAOIs; cimetidine may increase toxicity especially if taken in first 4 wk of therapy; carbamazepine may decrease primidone and phenobarbital levels (their coadministration may increase carbamazepine levels)

Documented hypersensitivity; history of bone marrow depression; administration of MAOIs within last 14 d

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Do not use to relief minor aches or pains; caution with increased intraocular pressure; obtain CBC counts and serum iron baseline prior to treatment, during first 2 months, and yearly or every other year thereafter; can cause drowsiness, dizziness, and blurred vision; caution while driving or performing other tasks requiring alertness


Gabapentin (Neurontin)

Has anticonvulsant properties and antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA but does not interact with GABA receptors. There are no firm rules, but, in elderly patients, less potentially anticholinergic medications like gabapentin may be a good first choice. Used as adjunct therapy.

Adult

Day 1: 100 mg tid or 300 mg hs
Day 2: 400 mg PO tid over 3 d and titrate prn; not to exceed 1200 mg PO qid
Titration to effect can take place over several days (300 mg on day 1, 300 mg bid on day 2, and 300 mg tid on day 3)

Pediatric

Not established

Antacids may reduce bioavailability of gabapentin significantly (administer at least 2 h following antacids); may increase norethindrone levels significantly

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in severe renal disease

More on Neoplastic Brachial Plexopathy

Overview: Neoplastic Brachial Plexopathy
Differential Diagnoses & Workup: Neoplastic Brachial Plexopathy
Treatment & Medication: Neoplastic Brachial Plexopathy
Follow-up: Neoplastic Brachial Plexopathy
References
Further Reading

References

  1. Kim DH, Murovic JA, Tiel RL. A series of 397 peripheral neural sheath tumors: 30-year experience at Louisiana State University Health Sciences Center. J Neurosurg. Feb 2005;102(2):246-55.

  2. Siqueira MG, Martins RS, Teixeira MJ. Management of brachial plexus region tumours and tumour-like conditions: relevant diagnostic and surgical features in a consecutive series of eighteen patients. Acta Neurochir (Wien). Sep 2009;151(9):1089-98. [Medline].

  3. Kori SH, Foley KM, Posner JB. Brachial plexus lesions in patients with cancer: 100 cases. Neurology. Jan 1981;31(1):45-50. [Medline].

  4. Killer HE, Hess K. Natural history of radiation-induced brachial plexopathy compared with surgically treated patients. J Neurol. Jul 1990;237(4):247-50.

  5. Kamenova B, Braverman AS, Schwartz M, et al. Effective treatment of the brachial plexus syndrome in breast cancer patients by early detection and control of loco-regional metastases with radiation or systemic therapy. Int J Clin Oncol. Jun 2009;14(3):219-24. [Medline].

  6. Gerevini S, Mandelli C, Cadioli M, Scotti G. Diagnostic value and surgical implications of the magnetic resonance imaging in the management of adult patients with brachial plexus pathologies. Surg Radiol Anat. Mar 2008;30(2):91-101. [Medline].

  7. Cross NE, Glantz MJ. Neurologic complications of radiation therapy. Neurol Clin. Feb 2003;21(1):249-77. [Medline].

  8. Dumitru D. Brachial plexopathy and proximal mononeuropathies. In: Electrodiagnostic Medicine. Philadelphia:. Hanley & Belfus Inc;1995:585-642.

  9. Harper CM Jr, Thomas JE, Cascino TL, Litchy WJ. Distinction between neoplastic and radiation-induced brachial plexopathy, with emphasis on the role of EMG. Neurology. Apr 1989;39(4):502-6. [Medline].

  10. Hathaway PB, Mankoff DA, Maravilla KR, et al. Value of combined FDG PET and MR imaging in the evaluation of suspected recurrent local-regional breast cancer: preliminary experience. Radiology. Mar 1999;210(3):807-14. [Medline].

  11. Kline DG, Judice DJ. Operative management of selected brachial plexus lesions. J Neurosurg. May 1983;58(5):631-49.

  12. Lachance DH, O''Neill BP, Harper CM Jr, et al. Paraneoplastic brachial plexopathy in a patient with Hodgkin''s disease. Mayo Clin Proc. Jan 1991;66(1):97-101.

  13. Liang R, Kay R, Maisey MN. Brachial plexus infiltration by non-Hodgkin''s lymphoma. Br J Radiol. Nov 1985;58(695):1125-7. [Medline].

  14. Meador KJ, Richards B, Hunter S, et al. Bibrachial palsy due to paraneoplastic encephalomyelitis. South Med J. Aug 1989;82(8):1053-5. [Medline].

  15. Mukherji SK, Castillo M, Wagle AG. The brachial plexus. Seminars in Ultrasound, CT and MRI. Semin Ultrasound CT MR. Dec 1996;17(6):519-38. [Medline].

  16. Pierce SM, Recht A, Lingos TI, et al. Long-term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer. Int J Radiat Oncol Biol Phys. 1992;23(5):915-23. [Medline].

  17. Stewart JB. The brachial plexus. In: Focal Peripheral Neuropathies. New York, NY:. Raven Press Ltd;1993:111-140.

  18. Weber RJ. Rehabilitation issues in plexopathies. In: Physical Medicine and Rehabilitation. Philadelphia: WB Saunders Co:. 990-1001.

  19. Wilbourn AJ. Brachial plexus disorders. In: Peripheral Neuropathy, PDPTJE. Philadelphia:. WB Saunders Co;1993:911-50.

  20. Wilbourn AJ. Electrodiagnosis of plexopathies. Neurol Clin. Aug 1985;3(3):511-29. [Medline].

Further Reading

Related eMedicine topics:
Radiation-Induced Brachial Plexopathy
Brachial Neuritis
Neonatal Brachial Plexus Palsies
Brachial Plexus Injuries, Traumatic
Brachial Plexus, MRI

Clinical guidelines:
ACR Appropriateness Criteria® plexopathy. American College of Radiology - Medical Specialty Society. 2006. 13 pages. NGC:005539

Clinical trials:
Radiation Therapy in Treating Women With Early Stage Breast Cancer

Keywords

neoplastic brachial plexopathy, brachial plexus, brachial plexus injury, brachial plexopathy, Pancoast syndrome, brachial plexus tumors, neoplasms of the brachial plexus, metastatic brachial plexopathy, neoplastic brachial palsy

Contributor Information and Disclosures

Author

Mark A Wren, MD, MPH, Medical Director, Department of Physical Medicine and Rehabilitation, HealthSouth Rehabilitation Hospital of Texarkana
Mark A Wren, MD, MPH is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Robert J Kaplan, MD, James E Van Zandt VA Medical Center, Staff Physician, Department of Rehabilitation Medicine
Robert J Kaplan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

 
 
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