Rehabilitation Program
Physical Therapy
Therapeutic modalities should focus on pain reduction, strengthening, preservation of range of motion, and limiting lymphedema. The interventions and modalities should address underlying impairments, as follows:
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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.
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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.
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Lymphedema: Educate the patient. Perform manual lymphatic therapy and motorized intermittent pneumatic compression therapy; use graded pressure upper extremity garments.
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Range of motion: Emphasis should be placed on a home exercise program to preserve range of motion and strength.
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.
Recommend 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.
Recreational Therapy
Focus on enjoyable activities that help to preserve range of motion and retain or build strength while limiting pain and discomfort.
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. Antibiotic treatment should be considered early if there is any indication of infection.
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
Dorsal root entry zone lesion or chemical sympathectomy 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.
Hyperbaric oxygen has not shown reproducible neurologic benefit.
Tables
Feature |
Tumor Infiltration |
Radiation Fibrosis |
Transient Radiation Injury |
Acute Ischemic Injury |
Incidence of pain |
80% |
18% |
40% |
Painless |
Location of pain |
Shoulder, upper arm, elbow, fourth and fifth fingers |
Shoulder, wrist, hand |
Hand, forearm |
Hand, forearm |
Nature of pain |
Dull ache in shoulder, lancinating pains in elbow and ulnar aspect of hand; occasional paresthesias and dysesthesias |
Ache in shoulder; prominent paresthesias in C-5/C-6 distribution of hand and arm |
Ache in shoulder; prominent paresthesias in C-5/C-6 distribution of hand and arm |
Paresthesias in C-5/C-6 distribution of hand and arm |
Severity |
Moderate to severe (severe in 98%) |
Usually mild to moderate (severe in 20-35%) |
Mild |
Mild |
Course |
Progressive neurologic dysfunction; atrophy and weakness in C-7/T-1 distribution, persistent pain; occasional Horner syndrome |
Progressive weakness; panplexus or upper plexus distribution; Horner syndrome uncommon |
Translate weakness with complete resolution |
Acute nonprogressive weakness and sensory loss |
Study findings |
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Magnetic resonance imaging |
High signal intensity on T2-weighted images; may enhance with gadolinium |
Low signal intensity on T2-weighted images; generally nonenhancing with gadolinium |
No data |
Normal |
Computed tomography |
Mass; circumscribed or diffuse tissue infiltration |
Diffuse tissue infiltration |
Normal |
Angiography demonstrates subclavian artery segmental obstruction |
Electromyography |
Segmental slowing |
Diffuse myokymia |
Segmental slowing |
Segmental slowing |
