eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy

Radiation-Induced Brachial Plexopathy: Treatment & Medication

Author: Robert J Kaplan, MD, James E Van Zandt VA Medical Center, Staff Physician, Department of Rehabilitation Medicine
Contributor Information and Disclosures

Updated: Jun 11, 2009

Treatment

Rehabilitation Program

Physical Therapy

The role of physical therapy does not differ much in cases of radiation-induced brachial plexopathy compared with tumor-related plexopathy. The interventions and modalities should address the following underlying impairments:

  • Weakness: Assign therapeutic exercise to enhance flexibility and strength of the shoulder girdle paracervical and parathoracic muscles. The glenohumeral joint may require a sling for sitting or standing activities to reduce the degree of glenohumeral joint subluxation and discomfort.
  • Pain: Use caution when considering the application of heat and cold if the sensation in the extremity is impaired. Transcutaneous electrical nerve stimulation therapy may be considered for pain control.
  • Lymphedema: Educate the patient. Perform manual lymphatic therapy and motorized intermittent pneumatic compression therapy; use graded pressure upper extremity garments.

Occupational Therapy

  • Assess basic and instrumental activities of daily living and provide appropriate adaptive equipment.
  • Provide fine motor skills training, if the lower plexus is involved.
  • Employ sensory and motor re-education techniques.
  • Consider using a flexor hinge tenodesis orthosis with or without long opponens orthosis if it allows the patient to be functionally prehensile.

Medical Issues/Complications

  • As with other conditions that produce lymphedema of the upper extremity, hygiene plays an important role in radiation-induced brachial plexopathy, and venipuncture should be avoided to obviate the risk of cellulitis/lymphangitis.
  • If the affected extremity is involved in trauma with skin laceration, exercise vigilance in monitoring for cellulitis or lymphangitis. Prophylactic antibiotic treatment, although controversial, can be initiated.

Surgical Intervention

  • Glenohumeral joint arthrodesis rarely is indicated.
  • Lymphatic bypass surgery interventions to divert or to redirect lymphatic flow rarely are required.

Consultations

A radiation oncologist, neuro-oncologist, neuroradiologist, and physical medicine/rehabilitation specialist can assist in diagnosis and management.

Other Treatment

One clinical investigation suggested that vasoactive pharmacotherapy with pentoxifylline in conjunction with alpha-tocopherol substantially reversed the course of radiation induced plexopathy. However, drug administration needs to be in temporal proximity to the course of radiation therapy.

  • Dorsal root entry zone lesion can be considered for intractable cases of chronic severe pain.
  • Neurolysis/decompression of the first rib or clavicle and neural grafting generally are not indicated.

Medication

The goal of pharmacotherapy is to reduce morbidity and prevent complications.

Anticonvulsants

Used to manage severe muscle spasms and provide sedation in neuralgia.


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.
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).

Adult

300-3600 mg/d PO divided tid/qid

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

Tricyclic antidepressants

Have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin.


Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain.

Adult

10-100 mg PO qhs

Pediatric

Not established

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase amitriptyline levels; amitriptyline 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; has 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, history of hyperthyroidism, and renal or hepatic impairment; avoid using in elderly patients


Nortriptyline (Aventyl, Pamelor)

Has demonstrated effectiveness in the treatment of chronic pain. By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, increases synaptic concentration of these neurotransmitters in CNS.

Adult

25 mg tid/qid PO; not to exceed 150 mg/d

Pediatric

Not established

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

Documented hypersensitivity; narrow-angle glaucoma; MAOIs in past 14 d

Pregnancy

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

Precautions

Caution in cardiac conduction disturbances, history of hyperthyroidism, and renal or hepatic impairment; due to pronounced effects in cardiovascular system, best to avoid in elderly patients

More on Radiation-Induced Brachial Plexopathy

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

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  2. Galecki J, Hicer-Grzenkowicz J, Grudzien-Kowalska M, et al. Radiation-induced brachial plexopathy and hypofractionated regimens in adjuvant irradiation of patients with breast cancer--a review. Acta Oncol. 2006;45(3):280-4. [Medline]. [Full Text].

  3. Schierle C, Winograd JM. Radiation-induced brachial plexopathy: review. Complication without a cure. J Reconstr Microsurg. Feb 2004;20(2):149-52. [Medline].

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  6. Sureka J, Cherian RA, Alexander M, et al. MRI of brachial plexopathies. Clin Radiol. Feb 2009;64(2):208-18. [Medline].

  7. Tung TH, Liu DZ, Mackinnon SE. Nerve transfer for elbow flexion in radiation-induced brachial plexopathy: a case report. Hand (N Y). Jun 2009;4(2):123-8. [Medline].

  8. Delanian S, Balla-Mekias S, Lefaix JL. Striking regression of chronic radiotherapy damage in a clinical trial of combined pentoxifylline and tocopherol. J Clin Oncol. Oct 1999;17(10):3283-90. [Medline].

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  13. Kori SH. Diagnosis and management of brachial plexus lesions in cancer patients. Oncology (Huntingt). Aug 1995;9(8):756-60; discussion 765. [Medline].

  14. Mondrup K, Olsen NK, Pfeiffer P, Rose C. Clinical and electrodiagnostic findings in breast cancer patients with radiation-induced brachial plexus neuropathy. Acta Neurol Scand. Feb 1990;81(2):153-8. [Medline].

  15. 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].

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Keywords

radiation-induced brachial plexopathy, brachial plexus, plexopathy, brachial plexopathy, radiation therapy, radiation treatment, breast cancer radiation therapy, breast radiation therapy, cancer radiation therapy, irradiation brachial plexopathy,

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Contributor Information and Disclosures

Author

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.

Medical Editor

Rajesh R Yadav, MD, Assistant Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas at Houston
Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

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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