Treatment strategies for chemotherapy-induced peripheral neuropathy: potential role of exercise

The role of exercise on peripheral nerve regeneration: from animal model to clinical application

Peripheral nerve injury is a complex condition with a variety of signs and symptoms depending on the severity and nerves involved. Peripheral nerve damage may lead to sensory and motor functions deficits and even lifelong disability, causing important socioeconomic costs worldwide. Despite the increase in knowledge of the mechanisms of injury and regeneration, a full functional recovery is still unsatisfying in the majority of patients. It is well known that exercise promotes physical and psychological well-being, by ameliorating general health. In the last years, there has been a growing interest in evaluating the effects of exercise on the peripheral nervous system. Experimental works with rodent models showed the potential utility of exercise following peripheral nerve injuries, as evinced by increasing axon regeneration, muscle reinnervation, better recovery of strength, muscle mass and higher expression of neurotrophic factors. Moreover, clinical evidence showed positive trends in favour of physical therapy following peripheral nerve damage based on the improvement of range of motion (ROM), muscle power grade and pain. After a brief overview of peripheral nerve anatomy and the different types of nerve injury, the present review aims to summarize the impact of exercise on peripheral nerve regeneration. Some clinical evidence regarding the effect of exercise after peripheral nerve injury will also be discussed.

Yoga for cancer survivors with chemotherapy-induced peripheral neuropathy: Health-related quality of life outcomes

Background

Yoga is a meditative movement therapy focused on mind‐body awareness. The impact of yoga on health‐related quality of life (HRQOL) outcomes in patients with chemotherapy‐induced peripheral neuropathy (CIPN) is unclear.

Methods

We conducted a pilot randomized wait‐list controlled trial of 8 weeks of yoga (n = 21) versus wait‐list control (n = 20) for CIPN in 41 breast and gynecological cancer survivors with persistent moderate to severe CIPN. HRQOL endpoints were Hospital Anxiety and Depression Scale (HADS), Brief Fatigue Inventory (BFI), and Insomnia Severity Index (ISI). The Treatment Expectancy Scale (TES) was administered at baseline. We estimated mean changes and 95% confidence intervals (CIs) from baseline to weeks 8 and 12 and compared arms using constrained linear mixed models.

Results

At week 8, HADS anxiety scores decreased −1.61 (−2.75, −0.46) in the yoga arm and −0.32 (−1.38, 0.75) points in the wait‐list control arm (p = 0.099). At week 12, HADS anxiety scores decreased −1.42 (−2.57, −0.28) in yoga compared to an increase of 0.46 (−0.60, 1.53) in wait‐list control (p = 0.017). There were no significant differences in HADS depression, BFI, or ISI scores between yoga and wait‐list control. Baseline TES was significantly higher in yoga than in wait‐list control (14.9 vs. 12.7, p = 0.019). TES was not associated with HADS anxiety reduction and HADS anxiety reduction was not associated with CIPN pain reduction.

Conclusions

Yoga may reduce anxiety in patients with CIPN. Future studies are needed to confirm these findings.

Clinical Trial Registration Number: ClinicalTrials.gov Identifier: NCT03292328.

Yoga for Chemotherapy-Induced Peripheral Neuropathy and Fall Risk: A Randomized Controlled Trial

Background

Chemotherapy-induced peripheral neuropathy (CIPN) is a common, debilitating side effect that worsens quality of life and increases the risk of falls in cancer survivors. Evidence of yoga’s safety and efficacy in treating CIPN is lacking.

Methods

In a randomized controlled study, we assigned breast and gynecological cancer survivors with persistent moderate-to-severe CIPN pain, numbness, or tingling with a score of 4 or greater (0-10 numeric rating scale [NRS]) for at least 3 months after chemotherapy to 8 weeks of usual care or yoga focused on breathwork and musculoskeletal conditioning. Primary endpoint was treatment arm differences for NRS, and secondary endpoints were Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity subscale (FACT/GOG-Ntx), and Functional Reach Test after week 8. We tested treatment arm differences for each outcome measure using linear mixed models with treatment-by-time interactions. All statistical tests were two-sided.

Results

We randomly assigned 41 participants into yoga (n = 21) or usual care (n = 20). At week 8, mean NRS pain decreased by 1.95 points (95% confidence interval [CI] = -3.20 to -0.70) in yoga vs 0.65 (95% CI = -1.81 to 0.51) in usual care (P = .14). FACT/GOG-Ntx improved by 4.25 (95% CI = 2.29 to 6.20) in yoga vs 1.36 (95% CI = -0.47 to 3.19) in usual care (P = .035). Functional reach, an objective functional measure predicting the risk of falls, improved by 7.14 cm (95% CI = 3.68 to 10.59) in yoga and decreased by 1.65 cm (95% CI = -5.00 to 1.72) in usual care (P = .001). Four grade 1 adverse events were observed in the yoga arm.

Conclusion

Among breast and gynecological cancer survivors with moderate-to-severe CIPN, yoga was safe and showed promising efficacy in improving CIPN symptoms.

Kinematic evaluation for impairment of skilled hand function in chemotherapy-induced peripheral neuropathy

INTRODUCTION

Chemotherapy-induced peripheral neuropathy (CIPN) usually affects both sensory and motor function of hands and feet, resulting in impaired skilled hand function (e.g., typing a keyboard). However, quantitative and objective evaluations for this condition have not been established.

PURPOSE OF THE STUDY

We evaluated skilled hand function using a kinematic analysis and investigated relationships among hand kinematic function and the clinical sensory and motor features of CIPN.

STUDY DESIGNS

Clinical measurement.

METHODS

Twelve CIPN patients and 12 age-matched control participants were enrolled. We recorded their reach and grasp movements using a three-dimensional measurement system, and calculated the normalized jerk of these movements as quantitative indexes of skilled hand function. Additionally, we used the number of sequential hand grip-release cycles in 10 seconds as an evaluation of clinical motor function.

RESULTS

Our kinematic analyses revealed significant difference in normalized jerk of grasp movement (CIPN: 3.7 ± 0.2, control: 3.4 ± 0.1; P = .005), but this was not the case for reach movement (CIPN: 2.5 ± 0.1, control: 2.5 ± 0.2; P = .43), indicating that the distal part of the forearm is particularly affected in CIPN. Such disturbed grasp movement was directly correlated with poor scores on the hand grip-release test and the sensory tests.

DISCUSSION

We revealed deficit impaired hand function objectively and quantitatively in CIPN patients using a kinematic analysis. Further, the hand grip test could represent such kinematic abnormality and could be useful for evaluating skilled hand function of CIPN patients.

CONCLUSIONS

Our kinematic and clinical measurements objectively and quantitatively evaluate skilled hand function in individuals with CIPN in clinical settings.

LEVEL OF EVIDENCE

Cross-sectional observational study.

Impact of Somatic Yoga and Meditation on Fall Risk, Function, and Quality of Life for Chemotherapy-Induced Peripheral Neuropathy Syndrome in Cancer Survivors

Objective. Chemotherapy-induced peripheral neuropathy (CIPN) syndrome causes significant pain as an adverse effect of treatment, with few nonpharmacological interventions tested. A somatic yoga and meditation (SYM) intervention on functional outcomes and quality of life (QOL) was investigated. Design and methods. Individuals diagnosed with CIPN were enrolled in an open-label, single-arm, mixed-methods feasibility trial. Participants and Setting. In an outpatient rehabilitation center, ten participants with median age 64.4 years (47-81) attended 61% of the sessions with no adverse events. Intervention. SYM twice a week for 8 weeks for 1.5 hours, with home program and journaling. Main outcome measures. Primary functional outcomes included Sit and Reach (SR), Functional Reach (FR), and Timed Up and Go (TUG). Self-reported Patient Neurotoxicity Questionnaire (PNQ) and Functional Assessment of Cancer Therapy—Neurotoxicity (FACT-GOG-NTX) were secondary CIPN outcomes. Biomarkers included salivary cortisol (stress) and bioesthesiometer (vibration). Results: Quantitative findings. Significant improvements were found in flexibility (SR; P = .006); balance (FR; P = .001) and fall risk (TUG; P = .004). PNQ improved significantly (P = .003) with other measures improving non-significantly. Qualitative findings. Five themes emerged: (1) vacillation of CIPN pain perception over time; (2) transferability of skills to daily activities; (3) improvement in physical function; (4) perceived relaxation as an effect of SYM; and (5) group engagement provided a social context for not feeling isolated with CIPN. Conclusion. Preliminary data suggest SYM may improve QOL, flexibility, and balance in cancer survivors with CIPN, with a fully powered randomized controlled trial indicated.

Trial registration: NCT03786055

Individually tailored whole-body vibration training to reduce symptoms of chemotherapy-induced peripheral neuropathy: study protocol of a randomised controlled trial-VANISH

INTRODUCTION

Chemotherapy-induced peripheral neuropathy (CIPN) is a prevalent and clinically meaningful side effect of cancer treatment. CIPN is induced by neurotoxic agents, causing severe sensory and/or motor deficits, resulting in disability and poor recovery, reducing patients' quality of life and limiting medical therapy. To date, effective treatment options are lacking. Whole-body vibration (WBV) training can attenuate motor and sensory deficits. We are conducting a two-armed, multicentre, assessor-blinded, randomised controlled trial, to investigate the effects of WBV on relevant symptoms of CIPN and determine the training characteristics.

METHODS AND ANALYSIS

In this ongoing study, 44 patients who have completed therapy in the past 3 months, with a neurologically confirmed CIPN are assessed before and after a 12-week intervention and follow-up. The intervention group receives WBV twice a week. Exercises are individually tailored according to the initially determined optimal neuromuscular response. The control group receives care as usual.Primary endpoint is the patient reported reduction of CIPN-related symptoms (Functional Assessment of Cancer Therapy/Gynaecology Oncology Group-Neurotoxicity). Secondary endpoints are compound muscle action potentials, distal motor latency, conduction velocity, F-waves from the tibial and peroneal nerve, antidromic sensory nerve conduction studies of the sural nerve, normalised electromyographic activity, peripheral deep sensitivity, proprioception, balance, pain, the feasibility of training settings, quality of life and the level of physical activity.

AIM, ETHICS AND DISSEMINATION

The study was approved by both responsible ethics committees. (1) Our results may contribute to a better understanding of the effects of WBV on motor and sensory functions and (2) may provide information whether WBV at the most effective setting, is feasible for neuropathic patients. (3) Our results may also contribute to improve supportive care in oncology, thereby enhancing quality of life and enabling the optimal medical therapy. All results will be published in international peer-reviewed journals as well as a manual for clinical practice.

TRIAL REGISTRATION NUMBER

NCT03032718.

Sensorimotor training and whole-body vibration training have the potential to reduce motor and sensory symptoms of chemotherapy-induced peripheral neuropathy-a randomized controlled pilot trial

Chemotherapy-induced peripheral neuropathy (CIPN) is a prevalent and clinically relevant side effect of chemotherapy. The symptoms diminish patients' quality of life and represent a decisive limiting factor for medical therapy. To date, effective treatment options are lacking. Specific exercise interventions have proven promising to target relevant symptoms. We conducted a prospective, four-armed, randomized, controlled trial, to evaluate the effects of sensorimotor training (SMT) and whole-body vibration training (WBV) on patients with CIPN. Participants (N = 40) were randomized to either one of two intervention groups (SMT N = 10 or WBV N = 10) or oncological control group (N = 10) and matched by gender and age with a healthy control (N = 10). The intervention groups exercised twice a week for 6 weeks. Primary endpoint was the reduction of CIPN-related symptoms (improve peripheral deep sensitivity, Achilles tendon reflex (ASR) and patellar tendon reflex (PSR), light-touch perception, sense of position, and lower leg strength). Secondary endpoints were nerve conduction velocity and amplitude, balance control, quality of life, and CIPN-related pain. Patients exercising improved sensory and associated motor symptoms. Significant intergroup differences were found for the tendon reflexes (ASR P = .017 and PSR P = .020), peripheral deep sensitivity (P = .010), and pain (P = .043). Furthermore, tendencies were found regarding the subjective improvement of symptoms (P = .075) and two subscales of the EORTC-QLQ-C30 questionnaire: pain (P = .054) and dyspnea (P = .054). The results for the SMT group were superior regarding the tendon reflexes, and a tendency regarding the subjective report of symptoms, while WBV was superior regarding pain. SMT and WBV behold a large potential to reduce CIPN-related symptoms and can be considered feasible and safe for patients with CIPN (compliance 97.5%, no adverse events).Registration: DRKS00013027.

The preventive effect of sensorimotor- and vibration exercises on the onset of Oxaliplatin- or vinca-alkaloid induced peripheral neuropathies - STOP

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a common and clinically relevant side effect of chemotherapy. Approximately 50% of all leukemia, lymphoma, colorectal- and breast cancer patients are affected. CIPN is induced by neurotoxic chemotherapeutic agents and can manifest with sensory and/or motor deficits. It is associated with significant disability and poor recovery. Common symptoms include pain, altered sensation, reduced or absent reflexes, muscle weakness, reduced balance control and insecure gait. These symptoms not only affect activities of daily living, subsequently reducing patients' quality of life, they have far more become a decisive limiting factor for medical therapy, causing treatment delays, dose reductions, or even discontinuation of therapy, which can affect the outcome and compromise survival. To date, CIPN cannot be prevented and its occurrence presents a diagnostic dilemma since approved and effective treatment options are lacking. Promising results have recently been achieved with exercise. We have revealed that sensorimotor training (SMT) or whole body vibration (WBV) can reduce the symptoms of CIPN and attenuate motor and sensory deficits. We furthermore detected a tendency that it may also have a preventive effect on the onset of CIPN.

METHODS

We are therefore conducting a prospective, multicentre, controlled clinical trial involving 236 oncological patients receiving either oxaliplatin (N = 118) or vinca-alkaloid (N = 118) who are randomized to one of two interventions (SMT or WBV) or a treatment as usual (TAU) group. Primary endpoint is the time to incidence of neurologically confirmed CIPN. Secondary endpoints are pain, maintenance of the functionality of sensory as well as motor nerve fibres as well as the level of physical activity. The baseline assessment is performed prior to the first cycle of chemotherapy. Subsequent follow-up assessments are conducted at 12 weeks, after completion of chemotherapy, and at a 3-month follow-up. Patients who develop CIPN receive an additional assessment at this time point, as it represents the primary endpoint.

DISCUSSION

We hypothesize that SMT and WBV prevent the onset or delay the progression of CIPN, decrease the likelihood of dose reductions or discontinuation of cancer treatment and improve patients' quality of life.

TRIAL REGISTRATION

Deutsche Register Klinischer Studien ( DRKS00006088 , registered 07.05.2014).

The Interdisciplinary Rehabilitation Care Team and the Role of Physical Therapy in Survivor Exercise

BACKGROUND

Rehabilitation professionals offer expertise in functional assessment, treatment of impairments and functional limitations, and disability prevention. To optimize recovery, and often prior to participating in community-based exercise programming, survivors may need rehabilitation services from a range of healthcare professionals, including physiatrists, nurses, nutritionists, psychologists, and speech, occupational, and physical therapists.

OBJECTIVES

Survivors with physical impairments and functional limitations may benefit from interdisciplinary rehabilitation and physical therapy, including tailored therapeutic exercise interventions.

METHODS

A literature review was conducted using the key words cancer survivor, cancer rehabilitation, impairment, fatigue, lymphedema, chemotherapy-induced peripheral neuropathy, and exercise. MEDLINE®, EMBASE, Cochrane Database of Systematic Reviews, and CINAHL® databases were searched.

FINDINGS

Nurses play a critical role in identifying survivors whose function or fitness is compromised to the point where participation in community-based exercise programming would be inappropriate or unsafe. The interdisciplinary rehabilitation care team can help facilitate the survivor's transition to community-based exercise programming.