Download Kathleen Brandfass, MS PT

Chemo Induced Peripheral Neuropathy
 Kathleen Brandfass, MS PT
 Director of Neuro,Vestibular and Geriatric
Outpatient Services
 UPMC/Centers for Rehab Services
Objectives
 1. Review Case presentation of Chemo Induced
Peripheral Neuropathy (CIPN)
 2. Introduce Chemotherapeutics/targets
 3. Types of CIPN
 4.Chemo toxicity side effects
 5. Future Research Targets
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Case Study
 JH: 64 y.o. Women
 Stage III ovarian cancer
 2005- bilateral salpino-oophorectomy
 Chemo s/p surg: 8 cycles
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Taxol
Carboplatin
 Chemo completed 12-2005
Case Study (cont)
 6-2006
 Evaluated by PCP- c/o numbness/tingling bilateral
hands and feet, imbalance h/o falls- worse with eyes
closed or walking in the dark.
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Case Study (cont)
7-2006- Referred to neurologist:
Motor- wasting bilateral extensor digitorium brevis
Strength: bilateral thumb/fingers 4-/5 rest UE 4/5
bilateral dorsiflexion 3-/5
bilateral Plantar flexion 3+/5 rest LE 4/5
Sensory:
Pin Prick/Vibration: Bilateral UE significant impairment
fingers to elbows ; elbows to shoulders normal
 Bilateral LE: absent toes to ankles ; significant
impairment to knees, normal knees to hips.
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Case Study ( cont)
 Proprioception:
 5/10 errors bilateral index fingers
 2/10 errors bilateral great toes
 Description: bilateral feet- high arched feet, hammer
toes, inverted wine bottle appearance distal legs.
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Case Study (cont)
 EMG:
 Evidence of severe , large fiber length-dependent
sensory-motor axonal polyneuropathy. Suggests
chronic process of ongoing acute denervation in
presence of high arched feet, hammer toes and
family h/o similar feet, possible the process is
secondary to an inherited neuropathy and acute
conduction denervation due to chemotherapeutic
agents.
Case Study (cont)
 Referral to PT :8-2006
 Going complaint of bilateral numbness and tingling
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hands and feet.
Imbalance: difficult to stand, trips when walking on even
floors at home, worse on uneven surfaces in dark or with
eyes closed , bending over in sink to wask face increasing
difficulty “holding” unto objects.
H/O fall
Ambualtion : WW bilateral AFOs
Severe ataxic pattern
Case Study: PT Eval
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Fatigue: Global Fatigue Scale: 80-90/100
Pain: 0/10
Dizziness: 5/10 with position changes.
Sensation/Strength: as reported
Balance: Romberg-EO- 30 sec/ EC-12 sec increased sway. Romberg
:foam EO- 14 sec/ EC 3 sec both conditions demonstrated increased
sway.
5XSTS:28sec
BBS:40/56
TUG: 27 sec- ww bilateral AFOs
DGI: 8/24
Gait Speed: 0.67 m/sec
Activities Specific Balance Confidence Scale: 34%
Cancer Survivorship
 After 5 years 60% of individuals diagnosed with all
types of cancer are still alive.
 Chemotherapy:
 Cytotoxic drugs are given for cancer treatments.
 Chemo agents interrupts the cell cycle: disrupts cell
 mitosis
Chemotherapeutics
 Chemo Drugs
 Taxane:
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Paclitaxel
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Docetaxel
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Abraxane
 Vinca Alkaloid
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Vincristine
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Vinorelbine
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Platinum
Cisplatin
Carboplatinum
Oxaliplatinum
Used to Treat
breast
lung
0varian
leukemia/lymphoma
sarcoma
lung
ovarian
sarcoma
Chemotherapeutics: Toxity
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Peripheral Nerve Toxicity:
Paclitaxel
Docetaxel
Thalidomides
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DRG Toxity:
Platinum Analogues
Doxrubicin
Suramin Sodium
Bortezomibs
Taxanes
Vinca Alkaloids
Chemo Toxicity
 Peripheral Nerve:
Axon Damage
Interrupts transport along axons by
interrupting ion exchange across cell membrane
 When chemo stopped ~ 80% of improvement occurs
within 6 months.
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Chemo Toxicity
 DRG:
 Acquired Sensory Neuron Disease
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60-70% of sensory
axons are unmyelinated C Fibers
Degeneration of short/long sensory axons and central
sensory processing projection in the posterior columns
“costing” effect- symptoms initiate and often persist
after discontinuation of chemo treatments
Symptoms: can includepain, burning, numbness/tingling,decreased fine
motor, changes in thermal sensitivity, CN:3,4,6,and 8
Chemotherapeutics: Sites
 Neuropathy can effect:
 Motor System
 Sensory System
 Autonomic System
Chemo Induced Peripheral Neuropathy (CIPN)
 CIPN factors:
 Which chemo agents used
 Dose and temporal pattern of delivery
 Health of the individual- functional reserve
 Risk Factors:
 Comorbid Peripheral Neuropathies
 balance impairments prior to treatment
 Visual Impairments
 Decreased peripheral vestibular function
Peripheral Neuropathy (PN)
 PN is not CIPN
 PN Comorbity could include:
 Diabetes
 GBS
 Axonal Neuropathies
 LS plexopathies
 CMT
 Miller Fischer Syndrome
 Chronic Inflammatory Polyradiculoneuropathiy
Chemotherapeutics: Side Effects
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Cancer Related Fatigue (CRF): Present 85-95%
Anemia/Leucopenia
Thrombocytopenia
CIPN
Sarcopenia
“Chemo Brain”
Osteoporosis
Dysregulation of sleep cycle
Mood changes
Incontinence
Premature menopause
Case Study
 Intervention:
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Education- CIPN- recognize symptoms
Ambulation- BWSTT /overground
Therapeutics Aquatics
Balance- static/transitional/dynamics challenges.
Epigentics and Cancer
 Epigentics : Study of hertiable changes to DNA
structure that does not alter the underlying
sequence.
 International Cancer Genome Consortium- initial
identification of patterns of recurrent somatic
mutations in protein-coding genes specific to a
variety of cancers
 Cancer epigentics is the area of emerging research
that is identifying the molecular pathogensis of
specific cancer types, assessing novel treatment
targets for an individual diagnosed with cancer.
Case Study
 Discharge Evaluation: (8-2008)
Strength- Bilateral dorsiflexors 4-/5, rest bilateral
LE 4+/5. Bilateral thumbs and fingers- 4/5, rest
bilateral UE 4+/5
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Sensory: pin prick/light touch /vibration:UE- min
decrease fingers to elbows, normal to shoulders. Min
decrease toes to midcalf, midcalf to hips normal.
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Proprioception: 0/10 errors bilateral index
fingers; 0/10 errors bilateral great toes.
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Case Study
 Discharge Evaluation (cont):
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Balance: romberg: even surface and foam-EO/EC: 30
sec . SLS right 24 sec, left 22 sec.
5XSTS: 8 sec
BBS: 50/56
TUG: 10 sec
DGI: 20/24
Ambulation: no assistive device, AFOs for long distances
Gait Speed: 1.01 m/sec
Activites Specific Balance Confidence Scale: 90%