Rehabilitation Program
Physical Therapy
For physical rehabilitation, the likely progression of neurologic weakness needs to be considered. If the patient is noted to have associated weakness after acute pain has subsided, one may recommend active range-of-motion (AROM) exercises, with advancement to low-resistance exercises. Assistive devices, such as a cane, walker, or wheelchair, may be required for ambulation in patients with weakness of the hip extensors, abductors, or quadriceps, with or without loss of joint position sense. Use of an ankle-foot orthosis (AFO) and, in rare cases, a knee-ankle-foot orthosis (KAFO) may be beneficial for mobility.
Occupational Therapy
The occupational therapist should assess activities of daily living (ADL) and prescribe appropriate adaptive equipment. In particular, be aware that standing-transfer safety may be impaired in cases in which involvement is more distal than proximal. With more proximal involvement, sit-to-stand transfers also may be affected. Equipment may be used specifically to facilitate dressing and bathing activities involving the lower extremity.
Medical Issues/Complications
Medical or surgical treatment of the carcinoma, when possible, is the first treatment of choice.
Intra-arterial chemotherapy regionally has limited use in patients with pelvic pain and intractable pain due to plexopathy.
The most commonly used treatment with such plexopathy involves radiation treatment. Subjective improvement has been noted in 85% of patients with regard to symptoms. Objective improvement, including neurologic improvement and reduction in measurable tumor size, has been noted in 48% of patients. However, the average response duration has been found to be only 4 months.
Pain management is an important issue and may require an analgesic ladder approach, including agents specifically for the management of neuropathic pain.
Neuropathic pain may respond to nerve stimulation, antidepressants, and antiepileptics.
Plexopathy-associated complications, such as contractures, deep venous thrombosis, immobility, and compressive neuropathies, should be anticipated, and early treatment should be provided.
Lymphedema in the lower extremities may be an issue and can be particularly difficult to treat. Treatment should focus on improving the swelling, thus improving pain and function. Initial intervention may include wrapping with nonelastic wrapping, elevation, appropriate retrograde massage techniques, ROM exercises, and education. With improvement in edema, compressive garments should be considered, although these may have to be of a custom type.
Surgical Intervention
Patients with more severe and recalcitrant pain may respond to the use of epidural catheter drug delivery and/or neurostimulatory/neuroablative surgical approaches. Cordotomies have been reported to have good outcomes in Europe. However, pain relief has been noted to be transient. Such ablative procedures carry the risk of sensory and motor deficits. The mortality rate has been significant at 5%.
Occasional relief of chronic pain has been achieved with plexus dissection and neurolysis. A study by Son et al indicated that in patients with terminal pelvic cancer, selective dorsal root rhizotomy can relieve intractable pain from neoplastic lumbosacral plexopathy. The study involved six patients who underwent the procedure, with their pain ratings and daily narcotic use found to have decreased postoperatively. [26]
Consultations
Pain is a significant issue in most patients and studies have shown that pain is often poorly controlled in these patients. A multidisciplinary approach is needed. Consider early consultation with pain service, given the patient's short life expectancy following diagnosis. These patients may benefit from opiate analgesics, continuous infusion pumps, and procedures such as local and regional blocks, sympathectomy, and rhizotomy.
Other Treatment
Nonpharmacologic measures, such as transcutaneous electrical nerve stimulation (TENS) or Anodyne therapy, may be used for neuropathic pain.
