Peripheral Neuropathy: Will it ever go away? Problems, Causes, Solutions


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Have you ever experienced peripheral neuropathy? Did it feel like a numbness or tingling in your hands or feet? Did it last several weeks, or several years? Join us, as Cindy S. Tofthagen, PhD, ARNP, AOCNP, University of South Florida College of Nursing Assistant Professor and Concentration Director of Oncology, will discuss this important topic and ways to manage it.

Although peripheral neuropathy is a known common side effect of some chemotherapy regimens, there are many different types of peripheral neuropathy, and many different causes. Cindy will explain exactly what it is that's happening, why it happens, and what causes it to happen. And then, most importantly, will provide tips on the best ways to manage it. You're not going to want to miss this!

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  • Preventative strategies have been the primary focus of research to date but have so far failed to provide effective methods to prevent it.Prevention may differ depending on neurotoxic agents the patient is receiving.Target underlying mechanisms behind CIPN, which are not well understood.
  • More research still needed because of small sample sizes in each study.
  • To measure side-effects associated with cancer treatments, large scale clinical trials often use grading scales, such as the National Cancer Institute’s (NCI) Common Toxicity Criteria for Adverse Events (CTCAE), WHO and ECOG scales.These criteria have been used to establish cut points for treatment toxicity, delays and/or reductions, rather than as comprehensive measures of the patient’s symptom experience. There are no guidelines for training of evaluators, no standardization of agreement as to what constitutes some subjective assessment of “weakness interfering with function”, ensuring wide variation ion scoring for the same patient presentation.In general, grading scales lack the sensitivity needed to capture the full impact of CIPN.
  • NP is often described as burning, shooting, stabbing, electric like, or pins and needles. An aggressive approach to pain management should be taken and may involve use of several different classes of medications.Pain is whatever the person says it is, experienced whenever the person says it is.
  • Requires aggressive treatment approach and frequent communication with the patientCaution: Even though these guidelines have been developed by experts and are evidence based, they may be of limited benefit for CIPN.A combination approach will probably be required.Add additional agents sequentially if partial but inadequate pain relief
  • Fall risk increases with each cycle of chemotherapy
  • These techniques may provide symptomatic relief ofnumbness and tingling for patients with CIPN with minimal foreseeable risks.
  • Allet and colleagues (2010) reported significantly improved balance and strength, increased walking speed, and decreased fear of falling in participants a 60 minute, twice a week for 12 weeks, strength, balance, and functional training program. The results were sustained for a period of six months. Furthermore, the training program was feasible and safe for persons with peripheral neuropathy.
  • Peripheral Neuropathy: Will it ever go away? Problems, Causes, Solutions

    1. 1. Welcome! Peripheral Neuropathy: Will it ever go away? Problems, Causes, Solutions Part of Fight Colorectal Cancer’s Monthly Patient Webinar Series Our webinar will begin shortly 877-427-2111
    2. 2. Fight Colorectal Cancer 1. Tonight’s speaker: Cindy Tofthagen, PhD, ARNP, AOCNP, FAANP 2. Archived webinars: 3. Follow up survey to come via email. Get a free Blue Star of Hope pin when you tell us how we did tonight. 4. Ask a question in the panel on the right side of your screen and look for hyperlinks during throughout the presentation. 5. Or call the Fight Colorectal Cancer Answer Line at 877-427-2111
    3. 3. Fight Colorectal Cancer Disclaimer The information and services provided by Fight Colorectal Cancer are for general informational purposes only. The information and services are not intended to be substitutes for professional medical advice, diagnosis, or treatment. If you are ill, or suspect that you are ill, see a doctor immediately. In an emergency, call 911 or go to the nearest emergency room. Fight Colorectal Cancer never recommends or endorses any specific physicians, products or treatments for any condition. 877-427-2111
    4. 4. Fight Colorectal Cancer Up coming webinar Advances in Surgical Treatments for Colon and Rectal Cancer Patients November 20, 2013 8 - 9:30pm EDT
    5. 5. Fight Colorectal Cancer Cindy Tofthagen, PhD, ARNP, AOCNP, FAANP University of South Florida College of Nursing 877-427-2111
    6. 6. Chemotherapy Related Neuropathy: Managing this Nerve Wracking Problem Cindy Tofthagen, PhD, ARNP, AOCNP, FAANP University of South Florida College of Nursing
    7. 7. Topics of Discussion • What is chemotherapy induced peripheral neuropathy (CIPN)? • What are the risk factors? • What can we do about it?
    8. 8. What is CIPN? A group of neuromuscular symptoms that result from nerve damage caused by drug therapies used in the treatment of cancer. Affects 30-100% of patients getting specific neurotoxic chemotherapy drugs. The most commonly used classes of drugs causing peripheral neuropathy are taxanes (Taxol and Taxotere) and platinum based drugs (cisplatin and oxaliplatin).
    9. 9. Symptoms •Sensory, motor, or autonomic •Vary from person to person based on type of treatment and individual differences •Numbness, tingling, and discomfort in the upper or lower extremities are the hallmarks of peripheral neuropathy
    10. 10. Problem CIPN can last for months to years after chemotherapy and sometimes is permanent. It can interfere with the ability to perform usual activities.
    11. 11. • Increasing dose • Pretreatment or concurrent treatment with other neurotoxic chemotherapies • Diabetes • Hypothyroidism • HIV infection • Charcot-Marie-Tooth disease • Autoimmune disorders • Vitamin B12 deficiency • Chronic alcohol abuse • Shingles
    12. 12. Supposedly chemotherapy increased my chances of living 5 years by 8%. I don’t want to live for another 5 years like this. My hands and fingers are numb. My feet are numb. My legs are numb from my knees to the bottom of my feet. I have pain, gnawing, burning, and cramping most of the time. My legs ache and feel stiff and heavy all the time. Driving is a problem, walking is a problem, Being on my feet is a problem. My hands don’t work. I feel collapsed, dizzy, and weak all day, every day, all the time. I have disabling fatigue. I feel like I have been poisoned. -written in 2008 by Sue, colorectal cancer survivor. (Tofthagen, 2010)
    13. 13. Functional Disability Peripheral Neuropathy Loss of Sensation Exaggerated Sensation
    14. 14. Walking Picking up things Driving Hobbies Sexual Activity Relationships Sleep Chores Exercise Writing Work
    15. 15. 1) Prevent it 2) Recognize it early 3) Control the pain 4) Minimize effects on quality of life
    16. 16. A variety of preventative strategies have been evaluated thus far with varying degrees of success, including: Calcium/Magnesium Infusions Alpha-lipoic acid B Vitamins Glutamine/glutathione Vitamin E
    17. 17. • Numerous clinical trials supporting its use • One trial was closed because of safety concerns • Recent meta-analysis confirmed safety and efficacy of Calcium and Magnesium infusions for prevention of neuropathy caused by oxaliplatin only • Reduces the incidence of grade 2 but not grade 1 neuropathy (Grothey et al., 2011; Hochster, Grothey, & Childs, 2007; Ishibashi, Okada, Miyazaki, Sano, & Ishida, 2010; Wen et al., 2012)
    18. 18. • Neurotoxicity may be directly related to individual variations in neurotoxic drug metabolism, distribution, and elimination. • Genetic polymorphisms associated with CIPN may lead to genetic tests to help identify individuals likely to develop severe neuropathy Bergmann, et al., 2011; Sissung, et al., 2006; Renbarger, et. al., 2008; Hertz, et al., 2012; Kroetz, et al., 2010; Schneider, et al., 2011.
    19. 19. • Early recognition is key because dose adjustments may be required that may lesson severity and minimize long-term nerve damage.
    20. 20. What to tell your healthcare team 1. What symptoms are you having? 2. Are the symptoms on one or both sides? 3. How much of the extremity is involved? 4. How severe and distressing is each symptom? 5. Are symptoms constant or do they come and go? 6. How are your activities and lifestyle being affected?
    21. 21. Controlling Neuropathic Pain Neuropathic pain is severe, difficult to treat, and may not respond well to narcotic analgesics. Image retrieved from
    22. 22. Describing Your Pain •Onset •Location •Duration •Characteristics •Aggravating Factors •Relieving Factors •Treatments tried
    23. 23. • Based on primary results (n=220) Duloxetine 60mg daily: • Diminishes CIPN pain in the majority • Improves function & QOL • One of the few drugs recommended that has data to support its use for painful CIPN
    24. 24. First Line Tricyclic Antidepressants Gapapentin or Pregabalin Second Line Serotonin-norepinephrine reuptake inhibitors Lidocaine Patch Third Line Tramadol or Controlled Release Opioid Fourth Line Cannabinoids, methadone, lamotrigine, topiramate, valproic acid Moulin, et al., 2007
    25. 25. Drug /Class Starting Dose Titration Maximum Dose Trial Duration Nortriptyline/T CA 25mg at bedtime Increase by 25mg every 3-7 days as tol 150mg/day 6-8 weeks Desipramine/T CA 25mg at bedtime Increase by 25mg every 3-7 days as tol 150mg/day 6-8 weeks Increase to 60mg/day in 7 days 60mg /BID 4 weeks Duloxetine/SSN 30mg/day RI Venlafaxine/SS NRI 37.7mg once or Increase by 75 twice a day mg/week 225mg/day 4-6 weeks Gabapentin 100-300mg TID 100-300mg TID every 1-7 days as tolerated 3600 mg/d (1200 mg 3 times daily) 3-8 wk for Titration and 2 weeks at max dose Pregabalin 50mg TID or 75mg BID Increase to 300mg/day after 3-7 days, then by 150mg/d every 3-7 days 600mg/d 4 weeks Dworkin, et al., 2010
    26. 26. Fall Risk Cycle Number Perceived Loss of Balance
    27. 27. Treatment of Foot Neuropathy Patients with numbness in the feet should: • • • • • • wear comfortable, properly fitting shoes avoid sandals, open toed or open heeled shoes inspect feet daily for injury avoid walking barefoot or in socks alone always check for foreign objects in shoes before putting them on change shoes in the middle of the day to avoid continued pressure in the same locations (Plummer & Albert, 2008).
    28. 28. Home Safety • Water temperature for bathing should be carefully assesses and the thermostat on the water heater should be adjusted to a maximum of 100 degrees Fahrenheit • Run cold water first • Use protective gloves when washing dishes • Always use pot holders (Armstrong, Almadrones, & Gilbert, 2005; Hot Water Burns Like Fire Campaign, 2006).
    29. 29. Home Safety • Living areas should be kept well lit • Keep walkways clear • Nightlights should be kept on in hallways, bathrooms and bedrooms, nonskid mats in the shower or bathtub (Armstrong, Almadrones, & Gilbert, 2005; Visovsky, Collins, Abbott, Aschenbrenner, & Hart, 2007).
    30. 30. Home Safety • • • • • • • • • Store frequently used items in easy-to-reach locations Remove throw rugs and mats Use sturdy chairs with arm rests Use a long handled reacher to pick up items from the floor Remove clutter around the house Install hand rails in the tub and beside the toilet Use a shower chair and a hand held shower Use hand railing when climbing stairs, Add a strip of brightly colored tape to the steps so that the outline of each step is clearly visible, • Keep walkways and stairs in good repair and free of clutter and debris
    31. 31. Self-Care Techniques • A study of self-reported self care techniques used by patients with related neuropathy (n=450) indicate techniques that patients found helpful in relieving symptoms include: • • • • • • • • warm baths (66%) walking (60%) massage (41%) rubbing cream on the feet (47%) elevating feet (57%) staying off the feet (59%) acupuncture (12%) meditation (20 (Nicholas et al., 2007)
    32. 32. • Compared to healthy people, persons with neuropathy have reduced proprioception, lower extremity sensation, and reduced ankle strength predisposing them to falls • Strength and balance training results in fewer falls • Safe for people with peripheral neuropathy • Tai Chi, a low impact form of Chinese martial art, may help reduce falls and improve balance (Gillespie et al., 2009; Morrison, Colberg, Mariano, Parson, & Vinik, 2010; Allet, et al., 2010; Kruse et al., 2010).
    33. 33. • Neurologist to establish/confirm diagnosis • Pain management • Physiatrist-physician who specialize in cancer rehabilitation, locate one at • Physical therapist -specific exercises designed to help improve muscle strength and balance • Occupational therapists -maintain your independence, adjust to physical limitations • Support groups and mental health professionals • Podiatrists –recommend footwear, and fit for orthotics (Tofthagen, 2012)
    34. 34. Summary • Neuropathy is an uncomfortable and distressing symptom that can interfere with your ability to do the activities you want and need to do on a daily basis. • Scientists are looking for ways to prevent neuropathy caused by chemotherapy. • Patients can get better control of neuropathy symptoms and their effects on quality of life by being aware of treatment options, communicating with their healthcare team and seeking out resources within their community.
    35. 35. Fight Colorectal Cancer CONTACT US Fight Colorectal Cancer 1414 Prince Street, Suite 204 Alexandria, VA 22314 (703) 548-1225 Toll-Free Answer Line: 1-877-427-2111 Email us: