Effects on the Neurologic System: Neuropathy

Authors: Ayda G. Nambayan, DSN, RN, St. Jude Children’s Research Hospital Erin Gafford, Pediatric Oncology Education Student, St. Jude Children’s Research Hospital; Nursing Student, School of Nursing, Union University Content Reviewed by: Judith Wilimas, MD, St. Jude Children’s Research Hospital Cure4Kids Release Date: 6 June 2006

Peripheral neuropathy (A- 1) is a disorder of the peripheral nervous system that results in motor or sensory loss in one or more nerves. In patients with cancer, peripheral neuropathy may be disease-associated (A – 2) and/or chemotherapy-induced (A – 3); the symptoms are generally transient but may last for many months after therapy is complete. Peripheral neuropathy is most often associated with vincristine (Oncovin).

Assessment

The patient with peripheral neuropathy may have a history that includes frequent falls, clumsiness, stumbling, an inability to hold things and difficulty in climbing. The patient may also have difficulty in playing with toys, especially small toys such as puzzles, because of compromise of fine motor skills that is secondary to neuropathy. The patient may experience tingling, numbness and the sensation of needle sticks and pin pricks in his or her fingers. Associated symptoms may include increased pain at night that disturbs sleep, constipation and increased injuries such as cuts, burns and frost bite.

Findings obtained by physical assessment are often bilateral and symmetric weakness, pain, diminished deep tendon reflexes (especially ankle jerk A- 4), decreased grasping ability and reduced muscle strength. The patient with peripheral neuropathy may also have changes in gait (ataxic gait). Areflexia (no response) may be found in as many as half of children and adolescents with peripheral neuropathy. Permanent paresthesia and footdrop (A – 5) are potential complications.

Planning

A plan of care is expected to result in the following:

- the patient’s comfort, which is achieved by adequate pain management, - the patient’s safety and protection from injury, - the prevention of permanent musculoskeletal complications through adequate patient and family education.

Module 7 - Document 19 Page 1 of 11 Effects on the Neurologic System: Neuropathy

Implementation

The primary goals of care for patients with peripheral neuropathy are prevention, early identification of the causative agent and prompt initiation of required therapy. Patients should undergo a baseline neurologic evaluation before they are given potentially neurotoxic chemotherapeutic agents. Regular evaluations should be conducted during treatment and after its completion to detect early signs of peripheral neuropathy. In some cases, cytoprotective agents are used in combination with neurotoxic agents. For example, the combination of amifostine (Ethyol) and cisplatin (Platinol) is sometimes administered.

Neuropathic pain is managed by pharmacologic (A – 6) and nonpharmacologic means. Pharmacologic agents such as analgesic, antidepressant and anticonvulsant medications are commonly used. Antidepressant drugs provide dual effects of pain relief and mood elevation. Nonpharmacologic strategies such as distraction, imagery visualization, relaxation and hypnosis have been reported to be helpful. Participation by the patient in occupational therapy and physical therapy is also beneficial in that these therapies provide muscle exercises and adaptive strategies to not only maintain independence but also minimize the risks of permanent damage.

Alternative (nonscientific) approaches include the use of salves, oils, liniments and relaxation techniques (A – 7). Medically supervised procedures such as acupuncture (A – 8) and biofeedback (A- 9) are also used to relieve the symptoms of peripheral neuropathy, especially pain. However, care should be taken to ensure that alternative therapies do not cause harm or further injury. It is a responsibility of the nurse to routinely conduct a thorough pain assessment and to continually evaluate the effectiveness of all pain management strategies used by the patient and the family.

Patient and Family Education

The nurse has the important responsibility of educating the patient and family about the relative risk for neuropathy, the recognition of early symptoms of peripheral neuropathy, and strategies for living with neuropathy.

Evaluation

The desired outcomes for patients experiencing peripheral neuropathy include adequate pain management, the prevention of musculoskeletal and integumentary complications and the successful adaptation to lifestyle limitations imposed by the neuropathy.

Module 7 - Document 19 Page 2 of 11 Effects on the Neurologic System: Neuropathy Helpful Web Links

Cancer Bacup.org,UK http://www.cancerbacup.org.uk/Resourcessupport/Symptomssideeffects/Othersymptomssideeffects/Peripheralneurop athy

Oncolink, Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA Managing Symptoms of Peripheral Neuropathy http://www.oncolink.com/coping/article.cfm?c=5&s=27&ss=52&id=577

Livestrong.org, Lance Armstrong Foundation, Austin, TX http://www.livestrong.org/site/c.jvKZLbMRIsG/b.670193/k.4151/Neuropathy_Detailed_Information.htm

The National Coalition for Cancer Survivorship http://www.canceradvocacy.org/search.jsp?query=neuropathy

Cancer Symptoms.org, Oncology Nursing Society, Pittsburgh, PA http://www.cancersymptoms.org/peripheralneuropathy/causes.shtml

Related www.Cure4Kids.org Seminars

Seminar #351 Neuromuscular Complications in a Patient with AML Leo Hamilton, MD, and Raja B. Khan, MD http://www.cure4kids.org/seminar/351

Seminar #875 Methotrexate-induced neurotoxicity Damon Reed, MD, and Fred Laningham, MD http://www.cure4kids.org/seminar/875

Module 7 - Document 19 Page 3 of 11 Effects on the Neurologic System: Neuropathy APPENDIX

A - 1 Peripheral Neuropathy

David M. Simpson, MD, Professor of Neurology, Mount Sinai School of Medicine, New York, NY; Director, Clinical Neurophysiology Laboratories, Mount Sinai Hospital, New York, NY

Go Back

Module 7 - Document 19 Page 4 of 11 Effects on the Neurologic System: Neuropathy

A – 2 Cancer and Peripheral Neuropathy

A tumor can directly infiltrate a nerve, compress a peripheral nerve or do both. The condition in which metastatic lesions directly infiltrate a spinal nerve or a spinal nerve root is called radiculopathy.

Tumors can produce antibodies or other substances that can cause generalized damage to the nerves (paraneoplastic peripheral neuropathy). Hodgkin disease, myeloma and cancer of the lung, breast or ovary are associated with this type of peripheral neuropathy.

Go Back

A – 3 Treatment-Related Peripheral Neuropathy

Surgical treatment of cancer and radiation therapy can damage nerves and cause neuropathy in the affected area. An example of this type of neuropathy is the numbness and tingling that can occur after spinal surgery for neuroblastoma.

Chemotherapeutic Agents Associated with Neuropathy CancerBACUP http://www.cancerbacup.org.uk/

 altretamine (Hexalen®)  azacytidine (in early-stage research trials)  carboplatin (Paraplatin®)  cisplatin  cladribine (Leustat®)  high-dose cytosine arabinoside (ara-C)  docetaxel (Taxotere®)  etoposide (Eposin®, Etopophos®, Vepesid®,)  fludarabine (Fludara®)  ifosfamide (Mitoxana®)  methotrexate (Maxtrex®) when it is given into the fluid around the spinal cord  oxaliplatin (Eloxatin®)  high-dose paclitaxel (Taxol®)  procarbazine  suramin (in early-stage research trials)  thalidomide  thiotepa  teniposide  vinblastine (Velbe®)  vincristine (Onconvin®)  vindesine (Eldisine®)  vinorelbine (Navelbine®)

Go Back

Module 7 - Document 19 Page 5 of 11 Effects on the Neurologic System: Neuropathy

A – 4 Ankle Jerk

In the patient with peripheral neuropathy, the ankle reflex is often scored as 1+ (diminished), 0.5+ (a reflex that is only elicited with reinforcement) or 0 (no response [areflexia]).

New York University School of Medicine, New York, NY The Precise Neurological Exam http://edinfo.med.nyu.edu/courseware/neurosurgery/reflexes.html

Go Back

A – 5 Foot Drop

DINF Disability INFormation Resources, Japanese Society for Rehabilitation of Persons with Disabilities (JSRPD), Tokyo, Japan http://www.dinf.ne.jp/doc/english/global/david/dwe002/dwe00260.htm

Go Back

Module 7 - Document 19 Page 6 of 11 Effects on the Neurologic System: Neuropathy

A – 6 Pharmacologic Management of Neuropathic Pain

 Analgesics that are effective in relieving nociceptive pain are less effective in treating neuropathic pain.  Tricyclic antidepressants, anticonvulsants, membrane stabilizers and capsaicin can relieve neuropathic pain.  Anticonvulsants have differing modes of action; therefore, failure to respond to one does not imply that others may not work.

Capsaicin is derived from the extracts of capsicum peppers. Applied topically, capsaicin causes reversible depletion of neurotransmitter substance P from the endings of sensory nerves; thus, capsaicin relieves pain. A major side effect is a burning discomfort that may lead to poor compliance.

Tricyclic antidepressants (TCAs) include amitriptyline, imipramine, desimipramine, clomipramine and the topical preparation doxepin. The analgesic effects of TCAs are independent of their antidepressant effects and depend upon their action on the noradrenergic pathways and their ability to block sodium channels. Side effects include dry mouth and somnolence.

Anticonvulsants that are effective in reducing seizure are also effective analgesics for neuropathic pain. This category of drug includes phenytoin (Dilantin), carbamazepine, lamotrigine and gabapentin. Anticonvulsants differ in their modes of action; therefore, if one drug does not produce the desired analgesic effect, another anticonvulsant with a different mode of action can be tried.

Baclofen relieves neuropathic pain by depressing the release of the excitatory neurotransmitters (glutamate and aspartate). This drug is particularly effective in treating trigeminal neuralgia.

Cholecystokinin (CCK) antagonists augment the effects of sustained-release morphine against neuropathic pain. The CCK antagonists can reverse opiate tolerance in cases of chronic pain. An example is proglumide.

Ketamine, when given in subtherapeutic doses, relieves neuropathic pain through its opiate- potentiating effects

Nerve blocks are achieved by the injection of local anesthetic agents into the perineural area. These agents are usually administered with corticosteroids to extend the period of pain relief.

Clonidine was first used as an antihypertensive agent. When given via the epidural and intrathecal route, clonidine causes analgesia by acting on the descending noradrenergic pathways.

Go Back

Module 7 - Document 19 Page 7 of 11 Effects on the Neurologic System: Neuropathy A – 7 Relaxation Techniques

Relaxation techniques are designed to release tension that could worsen pain. There are several techniques, such as breathing exercises, visualization, meditation, massage and yoga. Soothing music with visualization is most commonly used.

The following is a list of instructions for a particular relaxation technique.

1. Remove your shoes, and find a comfortable place to sit. Close your eyes, and become aware of your breath entering and leaving your body.

2. Slowly become aware of your body, starting from your feet and moving up to your legs. Follow your awareness to your buttocks, to their contact with the chair or cushion beneath you. Release any tension with your breath while you observe your body.

3. Bring your awareness to your back, moving along your spine and the muscles in your back. Now proceed to your pelvis and abdomen, paying attention to the way your abdomen moves when you breathe.

4. Become aware of your chest, to its rise and fall with each breath.

5. Now be aware of your hands resting in your lap. Without moving them, note each finger, the palms and the backs of your hands.

6. Move your awareness up your arms to your shoulders, neck and face, your lips, nose, eyes and the ears and the whole of your head.Gently return your awareness to your breathing and being “in the moment.”

Go Back

Module 7 - Document 19 Page 8 of 11 Effects on the Neurologic System: Neuropathy

A - 8 Acupuncture Acupuncture involves the insertion of very thin needles at specific points on the body. Many people believe that acupuncture is an effective therapy to reduce pain. For some people with peripheral neuropathy, acupuncture acts as a complementary therapy because it may reduce the need for pain-relieving drugs. Presently, research results as to whether acupuncture reduces chronic pain are mixed.

Go Back

Module 7 - Document 19 Page 9 of 11 Effects on the Neurologic System: Neuropathy

A – 9 Biofeedback Biofeedback is a therapy that enables people to learn how to voluntarily control autonomic body functions such as temperature, heart rate and muscle tension. In addition, biofeedback can be used to learn relaxation techniques that can reduce stress, headaches and chronic pain. The biofeedback approach is based on the principle that a desired outcome is learned when the information received indicates that a specific thought complex or action has produced the desired physiologic response.

Go Back

Module 7 - Document 19 Page 10 of 11 Effects on the Neurologic System: Neuropathy

Acknowledgments

Authors: Ayda G. Nambayan, DSN, RN, St. Jude Children’s Research Hospital Erin Gafford, Pediatric Oncology Student, St. Jude Children’s Research Hospital; Nursing Student, School of Nursing, Union University Content Reviewed by: Judith Wilimas, MD, St. Jude Children’s Research Hospital Edited by: Julia Cay Jones, PhD, ELS, Freelance Biomedical Editor, Memphis, TN Cure4Kids Release Date: 6 June 2006

Cure4Kids.org International Outreach Program St. Jude Children's Research Hospital 332 N. Lauderdale St. Memphis, TN 38105-2794

You may duplicate and redistribute this content in its entirety for educational purposes provided that the content is made available free of charge. This content may not be modified or sold. You can assist us in the development of additional free educational materials by sending us information about how and when you show this content and how many people view it. Send all comments and questions to [email protected].

Last printed 6/4/2008 10:24 AM Last Updated: 4 June 2008; AS X:\HO\IO Edu Grp\Projects\NURSING COURSE\NCEnglish\Edited\Module 7\M7 Final Revisions\NEM07D19V13.doc

Module 7 - Document 19 Page 11 of 11