Effects on the Neurologic System: Neuropathy 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