Proactive Rehabilitation for Chemotherapy-Induced Peripheral Neuropathy

https://doi.org/10.1016/j.soncn.2019.150983Get rights and content

ABSTRACT

Objective

To review assessment and management approaches for chemotherapy-induced peripheral neuropathy-related physical function deficits.

Data Sources

Peer-reviewed articles from PubMed, Ovid MEDLINE, CINAHL PsycINFO, SPORTDiscus, Scopus, and key studies’ reference lists.

Conclusion

Brief clinical tests (eg, gait, Timed Up and Go) can screen for neuropathy-related physical function deficits. Exercise and physical therapy may be promising treatments, but the efficacy and optimal dose of such treatments for chemotherapy-induced peripheral neuropathy are unclear.

Implications for Nursing Practice

Screening and assessment of neuropathy-associated physical function deficits should occur throughout neurotoxic chemotherapy treatment. If such deficits are identified, referral for rehabilitation (ie, physical or occupational therapy) and/or exercise interventions is warranted.

Introduction

Standard first-line treatments for many types of cancers include neurotoxic chemotherapy agents such as paclitaxel, docetaxel, oxaliplatin, cisplatin, and/or vinca alkaloids. Neurotoxic chemotherapy agents are thought to induce axon degeneration by interfering with axonal transport, mitochondrial function, and calcium2+-dependent ion channel function, among other possible mechanisms.1 Neurotoxic drug-induced axon degeneration commonly results in chemotherapy-induced peripheral neuropathy (CIPN). Many published reviews discuss CIPN incidence, clinical manifestations, and mechanisms based on age group (ie, adults and pediatrics) and neurotoxic chemotherapy treatment type.2, 3, 4, 5, 6, 7, 8 Briefly, sensory manifestations of CIPN may include numbness, tingling, neuropathic pain, and decreased vibration and pinprick sensibility in the upper and lower extremities; motor CIPN-related manifestations may include hyporeflexia, extremity weakness, and cramps2; and, while less common, autonomic manifestations may include dizziness, hearing loss, or constipation.3 Personal or cancer treatment-related factors that may affect the frequency or severity of CIPN symptoms include the cumulative amount of neurotoxic chemotherapy received during treatment,9,10 a diagnosis of diabetes,10,11 increased age,11,12 high body mass index,10,13,14 and low levels of moderate-vigorous physical activity before beginning chemotherapy.13 In a subset of patients receiving neurotoxic chemotherapy, CIPN symptoms may persist for years after the final chemotherapy infusion.15,16 Thus, in many instances, CIPN is a chronic condition that must be continuously monitored and managed during active cancer treatment and into survivorship.

A major consequence of sensory and motor CIPN symptoms is compromised physical function status,15,17 which negatively affects quality of life15,18 and may lead to chemotherapy dose modifications.19 While sensory CIPN symptoms are more frequent, up to approximately one third of patients develop motor CIPN during chemotherapy treatment and 11% continue to experience motor deficits up to 2 years post-treatment.15 The presentation of motor CIPN can vary by neurotoxic agent: with acute neuropathy, oxaliplatin commonly causes muscle cramps20; with cumulative neuropathy, vincristine leads to foot drop and gait impairments,5 and taxanes cause muscle weakness.2,8 Thalidomides, cisplatin, and bortezomib cause motor CIPN symptoms less frequently than do other neurotoxic drugs.3,8 Patients suffering from CIPN also exhibit decreased performance on objective functional tests such as hand grasp movement, hand grip strength,21 balance,22, 23, 24 stride-time, eyes-closed ankle sway,25 gross upper extremity movement,23 and walking/gait speed.17,26 CIPN-related deficits in fine or gross motor movements may increase difficulty with daily activities such as typing, driving, writing, walking, using a phone,27 and working.28,29

Although the detrimental effects of CIPN on physical function are well documented, these deficits are routinely underassessed and poorly managed in practice. Knoerl et al30 reviewed audio-recorded patient-clinician discussions and found that discussions of CIPN-related physical function deficits occurred in only 15 of 44 visits (34%) in which participants reported CIPN symptoms. Additionally, documentation of CIPN-related physical function deficits or motor assessments appeared in only 43 of 73 (59%) reviewed clinician notes.30 Because no CIPN prevention modalities exist,31 clinicians generally recommend neurotoxic chemotherapy dose modifications for management when patients report problems with physical function because of CIPN. However, as a first-line treatment for CIPN-related physical function deficits, these dose reductions are suboptimal because they may compromise treatment efficacy. Further, emerging evidence supports physical activity interventions (eg, exercise, strength training, physical therapy) for the rehabilitation of physical function deficits caused by CIPN.32, 33, 34, 35, 36, 37, 38, 39, 40 The purpose of this review is to give nurses an overview of the evidence about functional assessment methods and supportive care interventions that may help oncology patients manage CIPN-related physical function deficits during active cancer treatment and through survivorship. The evidence in this review may be used to increase the routine surveillance of CIPN and to identify patients with physical function deficits that may require additional supportive care interventions or referral to physical therapy.

Section snippets

Assessment of CIPN-Associated Physical Function Deficits

Much of the recent literature addressing the impact of CIPN on function has focused on identifying CIPN through self-reports of sensory symptoms. In multiple studies, greater severity of sensory CIPN symptoms has been associated with increased functional decline and fall risk.17,41,42 Mild and even moderate motor symptoms may be underestimated by patients and poorly assessed by clinicians.43 Although a wide variety of measurement modalities objectively and subjectively assess the CIPN symptom

Pharmacologic interventions

Managing painful CIPN is important to ameliorate suffering; in addition, patients with tolerable or minimal discomfort will be better able and willing to stay physically active and perform daily activities. Thus, clinicians should determine if the patient is suffering from painful CIPN and, when clinically indicated, offer treatments for pain. However, options for treating or preventing CIPN symptoms are limited, despite ongoing efforts by researchers to discover new pharmacologic treatments.

Conclusions and Implications for Clinical Care

Overall, CIPN-associated physical function deficits are common but often underassessed side effects of neurotoxic chemotherapy treatment that affect quality of life and effective chemotherapy dosing. The evidence summarized in this review suggests that several emerging strategies can help assess, manage, and improve CIPN-associated physical function deficits. Screening and assessment of CIPN-associated physical function deficits should occur following cancer diagnosis and continue throughout

Conflict of Interest

None.

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    • Occurrence and perceived effectiveness of activities used to decrease chemotherapy-induced peripheral neuropathy symptoms in the feet

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      Citation Excerpt :

      Our results suggest that survivors used a wide range of self-care activities, with over 92% using at least one activity. Given that no evidence-based interventions are available to prevent or treat CIPN (Colvin, 2019; Knoerl et al., 2020), our study provides evidence that survivors will engage in activities that they perceive may help to manage these severe and debilitating symptoms. The twelve activities that were used most frequently include eleven activities that could be self-initiated.

    View all citing articles on Scopus

    Funding: American Cancer Society Denny Hoelzer Sentinel Technologies Doctoral Scholarship in Cancer Nursing (grant no. DSCN-17-082-01 - SCN); Mittelman Integrative Oncology Family Fund; National Institute of Nursing Research, T32 (grant no. NR016914).

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