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CIPN: Chemotherapy Induced Peripheral Neuropathy CIPN describes the damage to the peripheral nervous system incurred by a patient who has received a chemotherapeutic agent that is known to be neurotoxic CIPN is the 2nd most common acute side effect of cancer intervention and it has been associated w...

CIPN: Chemotherapy Induced Peripheral Neuropathy CIPN describes the damage to the peripheral nervous system incurred by a patient who has received a chemotherapeutic agent that is known to be neurotoxic CIPN is the 2nd most common acute side effect of cancer intervention and it has been associated with gait and mobility deficits Severe CIPN has been associated with a 41% higher rate of falls when compared to those without neuropathy Damage to peripheral or autonomic nervous systems Depends on the type of chemo they had Occurs in up to 68% of chemo patients within the first 30 days of completion 30-83% w/ persistent neuropathy Generally distal and symmetrical Can be permanent or temporary Common sequelae due to Vincristine, Cisplatin, Taxol, Taxotere, Cytoxan Signs and Symptoms Paresthesia Usually fingertips or toes and can spread to hands and feet Decreased proprioception Decreased vibratory sense Neuropathic pain From PNS or CNS and can affect dermatomes Hyporeflexia or areflexia Distal muscle weakness Foot drop, may need AFO Postural instability/balance problems Difficulty with fine motor skills Blood pressure fluctuations autonomic nervous system Common Sensory Symptoms Mild to moderate numbness and tingling Burning/stabbing pain of hands and feet High cumulative dose = increased symptom severity Cold Hypersensitivity Common Motor Symptoms Weakness of distal muscles Decreased DTRs (usually achilles) Foot drop w/ high doses Management of CIPN Therapy Interventions Patient education AFO/orthotics/surface contact Desensitization techniques Not to ignore it Exercises to improve health and reduce inflammation Joint mobilizations/ MFR Gentle Compression/ Lymphatic stimulation Fall prevention recommendations Assistive device recommendations Medical Interventions Neurontin or gabapentin may be helpful Consider referral to pain management/ neurologist Simple Interventions Roker-bottom shoe soles and orthotics can help alleviate pressure on the feet Velcro straps and elastic laces can help with donning/ doffing shoes Stress mats in the home Sitting to do chores, such as grooming and working in the kitchen to avoid prolonged stance Low tech grooming devices, such as adaptive equipment to don shirts (buttons) and socks For the hands, adaptive equipment can include tools that are easy to use Thermal stress can be avoided by using gloves and warm socks in cold weather and potholders in the kitchen Voice activated smart phone/ devices can aid communications Voice activated software can aid computer use Radiation Fibrosis Pathologic development of fibrotic tissue sclerosis as a result of radiation Can be late consequence of XRT- developing several months to years after treatment Possible Risk Factors Age Overall health Medical ad degenerative disorders Diabetes already may have caused some degeneration of nerve tissue Cancer status Chemotherapy used Size of XRT field Location of XRT Type of XRT Effect on tendons/ligaments/bone Can cause progressive fibrosis and sclerosis resulting in loss of elasticity, shortening and contracture Can cause bone to become brittle and prone to injury Need to be monitored for osteopenia and osteoporosis Effect on vital organ systems Ulceration Mucosal fibrosis Hollow organ stenosis Cardiac and pulmonary fibrosis Radiation Induced Tissue Fibrosis Deep tissue work/ MFR After subacute stage of healing Tissue mobilization periphery Manual stretching Maintain ROM (AROM/AAROM) Prevention of chest wall adhesion Muscle/nerve adhesion Scar Tissue Management Scar mobilization/MFR Soft breast tissue Improve lymph circulation Improve UE/trunk ROM Provide desensitization Prevention of hypertrophy and adhesion AROM/PROM Brachial Plexopathy May occur as a result of radiation therapy Symptoms Pain, paresthesia, motor weakness C5-T1 nerve root distribution Onset could occur years after treatment Differential diagnosis Tumor recurrence Scapular Dyskinesia Decreased UE ROM Hypo: Soft tissue, GH joint Poor serratus function Long thoracic nerve injury Anterior protective posture Middle and lower trap weakness flip sign Soft tissue tightness incision, port a Cath Forward shoulders Pec minor tightness Address the perpetuating factors that are causing the dyskinesia, wok on motor control and PNF, strengthen the lower traps, teach them how to move properly, and then strengthening into full ROM. Axillary Web Syndrome A visible web of axillary skin overlying palpable cords of tissue Occurs following a lymph node dissection most commonly Cording begins in the axilla and extends to medial ipsilateral arm to antecubital space and base of thumb Limits shoulder, elbow, wrist ROM Cords are made taut and painful withs shoulder abduction and ER Subjective Symptoms Feels like “a string” It “pulls” when reaching forward and overhead My arm feels like it’s going to break when I straighten my elbow Key Facts The fibrous bands can extend from the axilla down the cubital fossa to the wrist Often occur within the first 8 weeks following surgery and can continue for an extended period of time (av. 12 weeks) Mixed evidence on incidence (36% BC patients) Treatment of Axillary Web Syndrome AROM and PROM of shoulder into flexion/abduction as well as elbow extension/supination and wrist extension as tolerated; PNF patterns Mobilization of fascia surrounding the shoulder and trunk Mobilization of axillary cording HEP including ROM exercises Additional research is needed into the best treatment strategies for this condition Sometimes you may hear “popping” of scar tissue Usually resolves on its own Breast Cancer Related Lymphedema 6-40% of breast cancer survivors will develop lymphedema Most common form of secondary lymphedema in the US A mechanical insufficiency of the lymphatic transport system, resulting in an accumulation of protein rich lymph fluids in the interstitial tissue Risk is dependent on the extent of cancer treatment and the system’s ability to compensate Highest incidence is found in combined axillary lymph node dissection w/ XRT (impedes the flow) Other probable/possible risk factors Obesity/BMI Advanced disease at diagnosis Post surgical infection/seroma Axillary cording Risk for developing lymphedema is lifelong Severity of Lymphedema Latency subclinical Stage I pitting, reversible w/ elevation Stage II little to no pitting, skin changes may begin to appear, irreversible with elevation Stage III non-pitting fibrotic, severe skin alterations, irreversible w/ elevation Subjective Signs and Symptoms of Lymphedema Slow onset typically distal to proximal Heaviness or full feeling in the affected arm, chest wall or trunk Tightness in the skin around the affected areas Difficulty fitting into clothing and jewelry Ex: Arm sleeve feels right, rings and bracelets are difficult to get on/off Quantitative Limb Volime Assessment Techniques Water displacement Circumferential measurements Perometer Bioelectrical Impedance Spectroscopy Measures the impedance to the flow of electrical current Single and multi-frequency; has been used for years in research settings in the US Does not work well when people become fibrotic, better for early stages 7.1 or above is considered to be a normal range Contraindications Pacemaker Cardiac defibrillator (ICD) Pregnancy Maybe metal implants Complete Decongestive Therapy (CDT) Phase I Reduction Compression bandaging They wear it 24/7 Manual Lymphatic Drainage Skin Care Therapeutic Exercise Patient Education Most important to teach self management Phase II Maintenance Compression garment (day) Compression bandaging (night) or night garment Therapeutic exercise MLD (PRN) Skin Care BCRL Treatment for those at Risk Follow risk reduction practices Assess the patient’s risk for developing BCRL and if they are in a “high risk” category discuss the option of wearing one prophylactically Someone who has had radiation, a axillary node dissection, etc. Exercises is safe for those at risk for BCRL and those with a diagnosis of BCRL Gradual progression of exercises encourages movement of fluids Rest if arm feels fatigued Exercise Guidelines for Cancer Survivors: Consensus Statement for International Multidisciplinary Roundtable 2019 Moderate intensity aerobic training at least 3x/week for 30 min Addition of resistance at least 2x/week at least 2 sets 8-15 reps Weight/resistance is at least 60% of 1 rep Stretching of all major muscle groups Supervised programs appear to be more effective than strictly unsupervised of home based Exercise patients per their tolerance and prescription vs. based solely upon the lab values Considerations when Developing Exercise Prescription Exercises should be individualized patient’s prior fitness level/ comorbidities Need for diverse exercise prescription to support needs of the individual (time, travel, cost, social factors can be barriers) Take into account persistent effects of cancer treatment Balance and persistent effect of neuropathy Steroid myopathy and other treatments Depression Consider age and other comorbidities in choosing types of exercises Reinforce to patient that exercises is beneficial before, during, and after cancer treatments. This includes patients with lymphedema Follow FITT Principle Special Considerations for Exercise Prescription in the Cancer Patient Monitor vital signs Make sure to take baseline measurements and monitor throughout the session Provide adequate rest breaks Patients with lymphedema should wear their compression garments when exercising HEP prescription Patient education is key Consider long term exercises/ wellness planning Blood count exercises prescription should be based on patient’s presentation, not blood count values alone Effects of medications/treatments Avoid aquatic therapy/ community pools if current radiation treatment or immunocompromised General Hematological Guidelines for Exercise RBC Normal 38-47% No exercises <25% Light exercise >25% Resistive exercise >25% Hemoglobin Normal 12-16.9 g/dL No exercises <8 g/dL Light exercise 8-10 g/dL Resistive exercise >10 g/dL Platelets Normal 200,000 – 400,000 mm3 No exercises <5000/ mm3 Light exercise 5000 – 50,000 mm3 Resistive exercise >50,000 mm3 WBCs Normal 4,000- 10,000 mm3 No exercises <500 mm3 Light exercise >500 mm3 Resistive exercise >500 mm3 Toxicities associated with Cancer treatments Increased risk for fractures decreased bone density, steroids, metastases, etc. Survivors with metastatic disease to the bone will require modification of exercise program (reduced impact, intensity, volume, etc.) CV events and risks related to certain types of chemo and targeted therapies Musculoskeletal morbidities secondary to treatment Cautions in determining activity level Bone metastases Thrombocytopenia Anemia Fever or active infection Limitations secondary to metastases or other comorbid illness Safety issues (falls) Monitoring Aerobic Fitness Have pt. learn RPE scale or heart rate target scale Modalities General use for pain relief/ control and desensitization TENs Heat hot pack and US Not during treatment After but not over site of metastasis No ultrasound during or after treatment, but 5 years post yes Cold Ice, cold laser Hair loss prevention during treatment After is allowed Cold laser yes Aquatic therapy **Always relative; case by case basis** Red Flags in Cance Rehab Altered mental status New palpable mass/ lymph node Quick exacerbation of lymphedema (especially proximal edema) Sudden increase or change in symptoms when it doesn’t correlate with what you are treating Consider that their pain m ay be a boney recurrence of cancer (especially prior to 5 year mark) Head and Neck Cancer 9/25/2023 Introduction Common sites of cancer tongue, tonsils, oropharynx, gums, floor of mouth Ongoing rise in cases linked to HPV infection in both men and women Common Treatment Approaches Neck Dissection Many varieties can include the excision of/or damage to the Spinal Accessory Nerve, the SCM, as well as removal of some to all lymph nodes in the region Reconstruction using flap from forearm; fibula, pec major Tracheostomy tube placement and gastrostomy tube placement Can be permanent or taken out XRT and Chemo Medications Often neurotoxic and cardiotoxic Platinum agents and taxanes are common, as well as methotrexate Possible Treatment Side Effects Surgery Swallowing/ breathing difficulties Facial/ cervical lymphedema CS and shoulder dysfunction Postural dysfunction Spinal accessory and/or facial nerve palsy Pain and limitations XRT Skin Burns Numbness/ paresthesia Generalized fatigue TMJ dysfunction/ trismus Brachial Plexopathy Chemotherapy Muscle and joint pain Peripheral neuropathy and hearing loss Pulmonary fibrosis Radiation Fibrosis Pathological development of fibrotic tissue sclerosis as a result of radiation Can be a late consequence of XRT – developing several months to years after treatment Risk Factors Age Overall health Medical and degenerative disorders Diabetes Already may have caused some degeneration of nerve tissue Cancer status Chemotherapy used Size of radiation field Location of radiation Type of radiation Effect on Nerves Can cause sclerosis of any level of neural structures Can result in pain. Sensory loss, and weakness Radiculopathy and plexopathy of cervical, brachial, or lumbosacral plexus Can result in pain as well as significant functional limitations Autonomic dysfunction Acute spinal cord compression Effect on Muscle Tissue Myopathy can occur Relative weakness, fatigue in affected muscles Ectopic activity in the motor nerve root Can result in sustained focal muscle contraction, which can create pain Effect on tendons/ligaments/bone Can cause progressive fibrosis and sclerosis resulting in loss of elasticity, shortening and contracture Can cause bone to become brittle and prone to injury Need to be monitored for osteopenia and osteoporosis Effect on vital organ systems Ulceration Mucosal fibrosis Hollow organ stenosis Cardiac and pulmonary fibrosis Effect on integumentary system Fibrosis, sclerosis Mucositis, dermatitis Erythema; blisters; sores can lead to infection Orthopedic Considerations Neck extensor weakness Shoulder pain and dysfunction Cervical dystonia Trismus Trismus Tonic contraction of muscles of mastication and results in a limited ability to open the mouth XRT often causes damage and fibrotic changes to muscles of mastication Depending on location of the C+XRT and its proximity to these structures as well as the time/ during radiation Can also be due to scar tissue build up from surgery and radiation therapy as well as nerve damage TMJ immobility can lead to degeneration of the TMJ Def mouth opening less than 30mm Referral to a therapist who specializes in TMJ is recommended Therabite option for individuals lacking mouth opening Helps stretch the tissue These patients are also at risk of developing lymphedema submentally and facially