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Brachial Plexus Injury: Treatment & Medication
Updated: Sep 5, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
At onset of injury, nonsteroidal anti-inflammatory drugs (NSAIDs), early mobilization, and moist heat packs are the favorable methods of treatment for acute injuries. In the subacute phase, a gradual progression from ROM activity to cervical and shoulder muscle strengthening is recommended.
Medical Issues/Complications
If symptoms persist (eg, persistent weakness, chronic neurapraxia) regardless of therapy, further consideration for additional imaging and referral should be undertaken.
Surgical Intervention
Surgical intervention is rarely needed, is injury-specific, and should be directed by a neurosurgical or orthopedic spine surgeon.
Consultations
Neurosurgery spine/orthopedic spine
Other Treatment
Manipulation is not recommended as a first line intervention, but it may be a helpful adjunct after full medical assessment has been completed.
Recovery Phase
Rehabilitation Program
Physical Therapy
In the recovery phase, cervical muscle strengthening and conditioning should be continued. Strength training programs are used to fully recover the strength that the athlete had prior to the injury. Training should be focused on muscles supporting the injured brachial plexus nerve, such as the shoulders and the surrounding cervical spine region. The neck also should be protected (eg, use of cervical neck rolls, cervical pillows) until strength is regained.
Consultations
If needed, continue follow-up care with a neurologist, and/or spine specialist.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Continued maintenance of cervical muscle strength, conditioning, and protection is recommended.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Opiate-Narcotics
Analgesia is important to obtain in the setting of brachial plexus nerve injuries. This can be accomplished by use of anti-inflammatory and/or opiate-narcotic medications. Analgesia may facilitate further assessment of the athlete, as well as their willingness to participate in therapy sessions.
Hydrocodone and acetaminophen (Lortab, Norcet, Vicodin)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab PO q4-6h prn
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
D - Unsafe in pregnancy
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; may cause drowsiness (Do not drive heavy machinery while taking medication)
Hydrocodone and ibuprofen (Vicoprofen)
Drug combination indicated for short-term (less than 10 d) relief of moderate to severe acute pain
Adult
1-2 tab PO q4-6h prn pain; not to exceed 5 tab/d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse 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; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; 3rd trimester of pregnancy
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in impaired renal function, peptic ulcer disease, impaired thyroid function, asthma, hypertension, edema, heart failure, increased intracranial pressure, and erosive gastritis; duration of action may increase in elderly patients
Oxycodone and acetaminophen (Percocet, Roxicet, Roxilox, Tylox)
Drug combination indicated for the relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn
Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Duration of action may increase in elderly patients; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/d of acetaminophen; higher doses may cause liver toxicity
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Have analgesic and antiinflammatory activities. Their mechanism of action is not known, but 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.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
600-800 mg PO tid prn
Pediatric
10 mg/kg/dose PO q6h
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse 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; monitor PT closely (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, or high risk of bleeding
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Ketoprofen (Oruvail, Orudis, Actron)
For relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse 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; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation 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
500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse 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; monitor PT closely (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 - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; 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
More on Brachial Plexus Injury |
| Overview: Brachial Plexus Injury |
| Differential Diagnoses & Workup: Brachial Plexus Injury |
 Treatment & Medication: Brachial Plexus Injury |
| Follow-up: Brachial Plexus Injury |
| References |
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References
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Cramer CR. A Reconditioning Program to Lower the Recurrence Rate of Brachial Plexus Neurapraxia in Collegiate Football Players. J Athl Train. 10 1999;34(4):390-396. [Medline].
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Sallis RE, Jones K, Knopp W. Burners. Offensive strategy for an underreported injury. Phys Sports Med. 20(11):47-55.
Stracciolini A. Cervical burners in the athlete. Pediatr Case Rev. Oct 2003;3(4):181-8. [Medline].
Weinberg J, Rokito S, Silber JS. Etiology, treatment, and prevention of athletic "stingers". Clin Sports Med. Jul 2003;22(3):493-500, viii. [Medline].
Weinstein SM. Assessment and rehabilitation of the athlete with a "stinger". A model for the management of noncatastrophic athletic cervical spine injury. Clin Sports Med. Jan 1998;17(1):127-35. [Medline].
Williams J, Hoeper E. Brachial plexus injury in a male football player. Curr Sports Med Rep. Jun 2004;3(3):125-7. [Medline].
Further Reading
Keywords
brachial plexus injury, stinger, burner, cervical nerve pinch syndrome, chronic burner syndrome, peripheral nerve injury
