Hand Therapy for Chemotherapy-Induced Peripheral Neuropathy



Hand Therapy for Chemotherapy-Induced Peripheral Neuropathy


Cynthia Cooper


Many people who have been treated with chemotherapy complain of upper extremity (UE) neuropathy that interferes with their activities of daily living (ADLs) including work and negatively impacts their overall quality of life. Certain chemotherapy agents are known to cause this problem but are necessary for best medical management. However, some patients have to discontinue their medication due to the severity of the neuropathy.1 For these patients, this difficult choice may shorten their lifespans.


In the oncology literature, there are no descriptions or acknowledgments of the value of hand therapy for patients with chemotherapy-induced UE neuropathy. Articles in oncology journals refer to rehabilitation but appear to define rehabilitation as medication only and do not mention the potential value of hand therapy. Likewise, hand therapy literature has not identified this population as a diagnostic group that could benefit from our services. To make matters more challenging, oncologists are not typically in the habit of referring their patients with neuropathy to hand therapy. For them to do so, we must spark their interest and their availability to learn about our services as hand therapists.



Definition of Chemotherapy-Induced Peripheral Neuropathy


Chemotherapy-induced peripheral neuropathy (CIPN) is defined as somatic or autonomic signs or symptoms resulting from damage to the peripheral nervous system (PNS) or autonomic nervous system (ANS) caused by chemotherapeutic agents.2 CIPN tends to be worse in patients with pre-existing nerve entrapments or neuropathies.3 It has been reported that 30% to 40% of patients receiving chemotherapy experience CIPN, and as more aggressive pharmacological agents are developed and survival rates increase in the future, this number is projected to grow.


Quality of life is adversely affected by CIPN, and symptoms can interfere with treatment resulting in a reduction of dosage or even discontinuation of life-sustaining medications.4 This is called a dose limiting factor. Currently there are no proven methods to treat CIPN.



Anatomy and Physiology Related to Chemotherapy-Induced Peripheral Neuropathy


Peripheral nerves are comprised of nerve fibers with varied myelination, morphology, functions, and chemical features. These differing fibers vary in their resistance to and response to the toxicity of chemotherapy drugs. Most nutritional, metabolic, and toxic neuropathies are axonopathies, meaning the pathology is axonal. The axon or the Schwann cell is typically the site of lesion.2



Any portion of the PNS or the central nervous system (CNS) or even muscle can be injured by anticancer drugs. Symmetrical distal polyneuropathy is the most common pattern of symptoms. Other patterns of peripheral nerve disease in CIPN are radiculopathy, plexopathy, polyradiculoneuropathy, mononeuropathy, and multiple mononeuropathy (also known as mononeuritis multiplex).



Symptoms



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While the deficits of CIPN can be sensory or motor or autonomic, most polyneuropathies are purely sensory.5 Paresthesias initially occur distally in a glove and stocking distribution and are worst on volar surfaces of the hands and plantar surfaces of the feet.



In CIPN, allodynia (experiencing pain with stimuli that is not typically painful) occurs especially in response to hot or cold. Motor impairment occurs less frequently and usually has a later onset. Purely autonomic symptoms are uncommon, but some autonomic involvement combined with PNS involvement is common.


Fine motor skills are affected, impairing activities, such as buttoning, donning earrings, doing clasps, and handling or manipulating small objects. Sensory ataxia is more severe when the eyes are closed or the lighting is low. Proprioceptive sensory disturbances also occur, as demonstrated by Romberg sign, which is a loss of balance that occurs when the patient stands with the eyes closed. Motor neuropathy presents with signs of weakness, cramps, atrophy, and fasciculation. Like sensory symptoms, the onset is typically distal. Findings of proximal weakness may be indicative of another condition, so be sure to mention this finding to the referring provider.


Nociceptive pain is defined as pain that is caused by structural dysfunction, such as a fracture. Neuropathic pain is defined as pain that is caused by peripheral nerve dysfunction and is typically sensory pain. This type of pain is difficult for patients to describe in words.







Diagnosis of Chemotherapy-Induced Peripheral Neuropathy


Simple clinical assessments are usually sufficient to diagnose CIPN. As noted earlier, nerve conduction studies are useful in identifying large myelinated fast conduction nerve involvement, but they do not identify small fiber dysfunction. In the oncology literature, scales of symptom severity describe levels of impact on ADLs. One such scale is the National Cancer Institute Grading: Common Terminology Criteria for Adverse Events (CTCAE) version 3.0 that scores neuropathic pain with grades 1-4.6 Another scale is the Total Neuropathy Scores (TNS) that reflects sensory, motor, autonomic, and strength symptoms with grades 1-4.2 The National Cancer Institute Common Toxicity Criteria–Version 3 scores motor and sensory symptoms with grades 1-5.1



Neuroplasticity


Hand therapists are experts on sensory reeducation and desensitization. These treatment programs are based on concepts of neuroplasticity, which refers to the fact that our brains can be reorganized neuronally in response to stimuli. Neuroplasticity involves learning, habituation, memory, and cellular recovery.7,8 Key concepts of neuroplasticity are:


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Sep 9, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Hand Therapy for Chemotherapy-Induced Peripheral Neuropathy

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