JPOXXX10.1177/1043454218762705Journal of Pediatric Oncology NursingSmolik et al. 762705research-article2018 Article Journal of Pediatric Oncology Nursing 2018, Vol. 35(4) 267 –275 Assessment Tools for Peripheral © 2018 by Association of Pediatric Hematology/Oncology Nurses Reprints and permissions: Neuropathy in Pediatric Oncology: sagepub.com/journalsPermissions.nav DOI:https://doi.org/10.1177/1043454218762705 10.1177/1043454218762705 A Systematic Review From the journals.sagepub.com/home/jpo Children’s Oncology Group Suzanne Smolik, RN, MSN, CPNP, CPON1, Lesley Arland, MS, PA-C1, Mary Ann Hensley, RN, BSN, CNOR, ONC1, Debra Schissel, RN, CPON, CCRP1, Barbara Shepperd, RN, CPHON, CCRP1, Kristin Thomas, PT, DPT1, and Cheryl Rodgers, PhD, RN, CPNP, CPON2 Abstract Peripheral neuropathy is a known side effect of several chemotherapy agents, including vinca alkaloids and platinum- based chemotherapy. Early recognition and monitoring of this side effect is an important role of the pediatric oncology nurse. There are a variety of peripheral neuropathy assessment tools currently in use, but the usefulness of these tools in identifying and grading neuropathy in children varies, and there is currently no standardized tool in place to evaluate peripheral neuropathy in pediatric oncology. A systematic review was performed to identify the peripheral neuropathy assessment tools that best evaluate the early onset and progression of peripheral neuropathy in pediatric patients receiving vincristine. Because of the limited information available in pediatric oncology, this review was extended to any pediatric patient with neuropathy. A total of 8 studies were included in the evidence synthesis. Based on available evidence, the pediatric–modified Total Neuropathy Scale (ped-m TNS) and the Total Neuropathy Score–pediatric version (TNS-PV) are recommended for the assessment of vincristine-induced peripheral neuropathy in children 6 years of age and older. In addition, several studies demonstrated that subjective symptoms alone are not adequate to assess for vincristine-induced peripheral neuropathy. Nursing assessment of peripheral neuropathy should be an integral and regular part of patient care throughout the course of chemotherapy treatment. Keywords systematic review, pediatrics, peripheral neuropathy, assessment tools Cancer treatment is associated with significant side sensory, motor, and autonomic neuropathy in children effects that impair individuals’ daily activities and health- (Gilchrist, 2012). These symptoms and physical assess- related quality of life. Side effects associated with che- ment findings are described in Table 1. A systematic review motherapy are numerous and well described in the of CIPN by Kandula, Park, Cohn, Krishnan, & Farrer literature. One side effect of chemotherapy that has a sig- (2016) found that vincristine-related neurotoxicity was nificant impact on the individual is peripheral neuropa- reported in 32 (52%) of the 61 studies. The most common thy, which can decrease mobility and limit independence vincristine-induced manifestations of CIPN are distal sen- with activities of daily living. Chemotherapy-induced sory loss in the lower extremities (sensory), distal symmet- peripheral neuropathy (CIPN) includes any injury, ric weakness in lower limbs progressing to foot drop inflammation, or degeneration of the peripheral nerves (motor), and constipation (autonomic) (Loprinzi, 2017). due to administration of a chemotherapeutic agent (Gilchrist, 2012), and may result in motor, sensory, and 1Children’s Hospital Colorado, Aurora, CO, USA autonomic nervous system symptoms. 2 Duke University School of Nursing, Durham, NC, USA Early and accurate identification of CIPN among pedi- atric patients with cancer is important. Vincristine and Corresponding Author: similar vinca alkaloid agents are essential in the treatment Suzanne Smolik, RN, MSN, CPNP, CPON, Solid Tumor Oncology, Children’s Hospital Colorado, 13123 East 16th Avenue, B-115, of many pediatric cancers, but they may also cause acute Aurora, CO 80045, USA. and long-term damage to peripheral nerves, leading to Email: [email protected] 268 Journal of Pediatric Oncology Nursing 35(4) Table 1. Symptoms and Physical Assessment Findings Associated With Chemotherapy-Induced Peripheral Neuropathy.a Sensory Motor Autonomic Paresthesia Weakness (usually in lower limbs) Constipation Dysesthesia (abnormal sensations) Foot drop Blood pressure alterations Pain Gait or balance disturbance Urinary retention Numbness and tingling Fine motor skills dysfunction Diminished or absent reflexes Diminished or absent vibratory sensations Diminished or absent cutaneous sensation aInformation from Loprinzi (2017) and Biedrzycki (2015). The incidence of vincristine-induced acute neuropa- physical therapist, orthopedic surgical registered nurse, thy has been noted to be as high as 100% in children, and 2 research oncology registered nurses. A doctorally while severe peripheral neuropathy occurs in approxi- prepared nurse researcher from the COG Nursing mately 10% of the children with cancer (Kandula et al., Discipline served as the project mentor. 2016). Most CIPN resolves within 3 months after com- A medical librarian and research assistant conducted pletion of chemotherapy; however, some symptoms the electronic search of 4 databases, including PubMed, may persist, especially symptoms caused by vincristine CINAHL, Cochrane, and the National Guidelines (Loprinzi, 2017). Clearinghouse. Key terms guiding the search were Monitoring and accurately reporting side effects dur- peripheral neuropathy, pediatric, and assessment. ing clinical trials of treatment regimens for cancer is vital. Vincristine and oncology were not included as key terms There are a variety of peripheral neuropathy assessment to obtain all available evidence focused on pediatric tools currently in use, but the accuracy of these tools in peripheral neuropathy assessment. Due to the limited lit- identifying neuropathy in children varies. Young children erature related to pediatric patients with cancer with with limited vocabulary may be unable to describe the peripheral neuropathy, the search was expanded to all sensations or deficits that are associated with peripheral pediatric diseases. All published years were included in neuropathy. Reliable tools must be identified and used the literature search with English used as the only limit. when evaluating neuropathy in children during and after The original search yielded 182 articles, with 2 additional they receive chemotherapy. Currently, there is not one articles located by hand searching, which were duplicates consistently used tool to measure CIPN in children with (Figure 1). No clinical guidelines relevant to the PICOT cancer. Therefore, a systematic review was performed to question were identified. The team reviewed all 182 describe the reliability of CIPN assessment tools for chil- abstracts to determine if the articles met the inclusion cri- dren receiving vincristine. teria. The inclusion criteria consisted of research-based A PICOT question was developed to focus the system- articles that included an evaluation of a peripheral neu- atic review. PICOT represents Patient, Intervention or ropathy assessment tool with participants aged 1 to 18 Issue of Interest, Comparison, Outcome, and Time years. After excluding articles that did not meet the inclu- (Melnyk & Fineout-Overholt, 2015). The following sion criteria, the number of available articles for use as PICOT question was used to guide this review: “In pedi- evidence sources was reduced to 8. Five articles were atric patients receiving vincristine, what assessment tools focused on children with cancer, and 3 articles were best evaluate early onset and progression of peripheral focused on children with type 1 diabetes. neuropathy?” Matrix tables (Garrard, 2014) were used to extract key information and to summarize the following components Systematic Review Methods of each article: purpose, design, variables, settings/sub- jects, measurement and instruments, and results/implica- An evidence-based practice (EBP) project proposal was tions. In addition, the quality of each article was evaluated submitted and approved by the Children’s Oncology Group using the Grading of Recommendations, Assessment, (COG) Nursing Discipline under the COG Nursing Development, and Evaluations (GRADE) criteria (Guyatt Evidence-Based Practice initiative. This initiative is et al., 2011) and issues with methodological flaws, incon- designed to address clinical issues not typically broached sistencies, indirectness, imprecision, and publication bias in protocols but pertinent to the nursing care of patients were noted on the matrix tables. The matrix table for each throughout therapy. The evidence-based review team con- article was completed by 1 team member, who then sisted of a pediatric nurse practitioner, physician assistant, presented the information to the group via a monthly Smolik et al. 269 Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. conference call, where the summary and quality issues Peripheral Neuropathy Assessment Tool were reviewed and agreed upon by group consensus. Evidence A total of 8 studies are included in the evidence synthesis. Evidence Review Three studies evaluated the ped-m TNS tool among pedi- Peripheral Neuropathy Assessment Tools atric patients with cancer, 2 studies evaluated the TNS-PV tool among pediatric patients with cancer, and the