A randomized exploratory phase 2 study in patients with chemotherapy-related peripheral neuropathy evaluating whole-body vibration training as adjunct to an integrated program including massage, passive mobilization and physical exercises

Non-pharmacological therapy for chemotherapy-induced peripheral neurotoxicity: a network meta-analysis of randomized controlled trials

BACKGROUND

Chemotherapy-induced peripheral neurotoxicity (CIPN) is the most common adverse effect in patients undergoing chemotherapy, and no effective interventions are currently available for its prevention and treatment. Non-pharmacological therapies appear to be beneficial for the prevention and treatment of CIPN, but it remains unclear which therapy is most effective. The aim of this study was to identify the most effective non-pharmacological therapy for CIPN patients.

METHODS

PubMed, Web of Science, Embase, and Cochrane Library were searched for randomized controlled trials on non-pharmacological therapies for CIPN. The primary outcomes included pain and peripheral neuropathological symptoms, and the secondary outcomes included quality of life, sensory and motor symptoms. The pairwise analysis and a network meta-analysis were performed using a random effects model.

RESULTS

A total of 46 articles were included in this study, involving 2,878 participants. Our study showed that massage was more effective in pain-alleviating compared with acupuncture [SMD = 0.81, 95%CI (0.04, 1.57)], vitamin and gabapentin [SMD = 2.56, 95%CI (1.39, 3.74)], and usual care and placebo [SMD = 0.9, 95%CI (0.31, 1.49)]. As for attenuating peripheral neuropathological symptoms, massage was more effective than usual care and placebo [SMD = 0.75, 95%CI (0.33, 1.17)], sensorimotor training [SMD = 1.17, 95%CI (0.24, 2.10)], electrostimulation [SMD=-1.18, 95%CI (-2.14, -0.21)], multimodal exercise [SMD=-0.82, 95%CI (-1.57, -0.08)], and resistance training [SMD = 1.03, 95%CI (0.11, 1.95)]. Massage was also more effective than other non-pharmacological therapies in improving quality of life, sensory and motor symptoms.

CONCLUSIONS

According to our study, massage has advantages in alleviating pain, improving quality of life, and improving peripheral neuropathological symptoms and has better effect than other non-pharmacological interventions, representing certain clinical significance. However, the results of this study should be interpreted with caution due to the limitations of the included studies. In the future, more high-quality multi arm randomized controlled trials can be attempted to provide direct comparisons of the relative effects of non-pharmacological interventions.

A precision-based exercise program for patients with multiple myeloma

OBJECTIVES

Aim of this study was to retrospectively evaluate an interdisciplinary consultation followed by a precision-based exercise program (PEP) for myeloma patients with stable and unstable bone lesions.

METHODS

Data of myeloma patients (n = 100) who received a PEP according to an orthopedic evaluation were analyzed. Bone stability was assessed by established scoring systems (Spinal Instability Neoplastic Score [SINS], Mirels' score). All patients with stable and unstable osteolyses received a PEP and n = 91 were contacted for a follow-up interview.

RESULTS

In 60% of patients at least one osteolysis of the spine was considered potentially unstable or unstable. Following consultation, the number of patients performing resistance training could be significantly increased (≥2 sessions/week, 55%). Musculoskeletal pain was reported frequently. At the follow-up interview, 75% of patients who performed PEP stated that painful symptoms could be effectively alleviated by exercise. Moreover, only patients who exercised regularly discontinued pain medication. No injuries were reported in association with PEP.

CONCLUSION

We were able to demonstrate that individualized resistance training is implementable and safe for myeloma patients. By means of a PEP, patients' self-efficacy in managing musculoskeletal pain was enhanced and pain medication could be reduced.

Effects of exercise on chemotherapy-induced peripheral neuropathy in cancer patients: a systematic review and meta-analysis

PURPOSE

Summarize and critically evaluate the existing studies to determine the effects of exercise on chemotherapy-induced peripheral neuropathy in cancer patients.

METHODS

We searched PubMed, Scopus, Web of Science, and Cochrane Library databases for randomized controlled trials reporting exercise intervention in cancer patients with chemotherapy-induced peripheral neuropathy. The outcomes of interest included chemotherapy-induced peripheral neuropathy symptoms, physical function (balance control, muscle strength, and functional status), and quality of life. The Cochrane Collaboration's tool was employed to assess the risk of bias.

RESULTS

The search identified 1309 studies, 16 of which eligible. Our meta-analysis revealed that exercise intervention significantly improved the quality of life (SMD = 0.83, 95% CI = 0.58 to 1.08, I² = 0%, P < 0.00001) and relieved neuropathic pain (MD =  - 4.93, 95% CI =  - 5.60 to - 4.26, I² = 0%, P < 0.00001). The muscular strength of the upper (SMD = 1.10, 95% CI = 0.68 to 1.51, I² = 25%, P < 0.00001) and the lower limbs (SMD = 0.84, 95% CI = 0.42 to 1.26, I² = 36%, P < 0.00001) increased and balance performance (SMD = 1.05, 95% CI = 0.62 to1.48, I² = 0%, P < 0.00001) was better in the exercise group than in the group with usual care. However, no evidence was found that exercise intervention could improve CIPN symptoms.

CONCLUSIONS

The results of this study showed that combined exercise could be an effective option for improving quality of life, physical function (balance control and muscle strength), and neuropathic pain in cancer patients with chemotherapy-induced peripheral neuropathy. Further exploration of appropriate exercise prescriptions is needed to improve other outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

Specific and appropriate exercise intervention for cancer patients with chemotherapy-induced peripheral neuropathy should be recommended because these interventions can improve their quality of life and physical function.

Influence of vibrotactile random noise on the smoothness of the grasp movement in patients with chemotherapy-induced peripheral neuropathy

Patients with chemotherapy-induced peripheral neuropathy (CIPN) often suffer from sensorimotor dysfunction of the distal portion of the extremities (e.g., loss of somatosensory sensation, numbness/tingling, difficulty typing on a keyboard, or difficulty buttoning/unbuttoning a shirt). The present study aimed to reveal the effects of subthreshold vibrotactile random noise stimulation on sensorimotor dysfunction in CIPN patients without exacerbating symptoms. Twenty-five patients with CIPN and 28 age-matched healthy adults participated in this study. To reveal the effects of subthreshold vibrotactile random noise stimulation on sensorimotor function, participants were asked to perform a tactile detection task and a grasp movement task during random noise stimulation delivered to the volar and dorsal wrist. We set three intensity conditions of the vibrotactile random noise: 0, 60, and 120% of the sensory threshold (Noise 0%, Noise 60%, and Noise 120% conditions). In the tactile detection task, a Semmes-Weinstein monofilament was applied to the volar surface of the tip of the index finger using standard testing measures. In the grasp movement task, the distance between the thumb and index finger was recorded while the participant attempted to grasp a target object, and the smoothness of the grasp movement was quantified by calculating normalized jerk in each experimental condition. The experimental data were compared using two-way repeated-measures analyses of variance with two factors: experimental condition (Noise 0, 60, 120%) × group (Healthy controls, CIPN patients). The tactile detection threshold and the smoothness of the grasp movement were only improved in the Noise 60% condition without exacerbating numbness/tingling in CIPN patients and healthy controls. The current study suggested that the development of treatment devices using stochastic resonance can improve sensorimotor function for CIPN patients.

Prevention and Treatment of Chemotherapy-Induced Peripheral Neuropathy (CIPN) with Non-Pharmacological Interventions: Clinical Recommendations from a Systematic Scoping Review and an Expert Consensus Process

Background: Most individuals affected by cancer who are treated with certain chemotherapies suffer of CIPN. Therefore, there is a high patient and provider interest in complementary non-pharmacological therapies, but its evidence base has not yet been clearly pointed out in the context of CIPN. Methods: The results of a scoping review overviewing the published clinical evidence on the application of complementary therapies for improving the complex CIPN symptomatology are synthesized with the recommendations of an expert consensus process aiming to draw attention to supportive strategies for CIPN. The scoping review, registered at PROSPERO 2020 (CRD 42020165851), followed the PRISMA-ScR and JBI guidelines. Relevant studies published in Pubmed/MEDLINE, PsycINFO, PEDro, Cochrane CENTRAL, and CINAHL between 2000 and 2021 were included. CASP was used to evaluate the methodologic quality of the studies. Results: Seventy-five studies with mixed study quality met the inclusion criteria. Manipulative therapies (including massage, reflexology, therapeutic touch), rhythmical embrocations, movement and mind-body therapies, acupuncture/acupressure, and TENS/Scrambler therapy were the most frequently analyzed in research and may be effective treatment options for CIPN. The expert panel approved 17 supportive interventions, most of them were phytotherapeutic interventions including external applications and cryotherapy, hydrotherapy, and tactile stimulation. More than two-thirds of the consented interventions were rated with moderate to high perceived clinical effectiveness in therapeutic use. Conclusions: The evidence of both the review and the expert panel supports a variety of complementary procedures regarding the supportive treatment of CIPN; however, the application on patients should be individually weighed in each case. Based on this meta-synthesis, interprofessional healthcare teams may open up a dialogue with patients interested in non-pharmacological treatment options to tailor complementary counselling and treatments to their needs.

Effectiveness of a Therapeutic Exercise Program to Improve the Symptoms of Peripheral Neuropathy during Chemotherapy: Systematic Review of Randomized Clinical Trials

BACKGROUND

Therapeutic exercise has an important role to manage chemotherapy-induced peripheral neuropathy symptoms. However, there is little evidence of its effectiveness.

OBJECTIVE

To synthesize the evidence regarding therapeutic exercise during chemotherapy to improve peripheral neuropathy symptoms.

DATABASES

PubMed, CINAHL, Cochrane Library, PEDro, ScienceDirect, Scopus, Web of Science and BIREME.

METHODOLOGY

Randomized clinical trials were included. GRADE was used to synthesize evidence and an inverse variance model for meta-analysis.

RESULTS

Up to May 2022, 2172 references were analyzed and 14 studies that evaluated 1094 participants were included. The exercises were highly effective in improving pain threshold and moderately effective in improving peripheral neuropathy symptoms at the 8-week follow-up and the 4-24 weeks. Furthermore, the evidence was low in improving thermal threshold, tactile and vibratory sensitivity.

CONCLUSION

Therapeutic exercise generates a significant reduction in peripheral neuropathy symptoms in patients in short- and long-term follow-up with a moderate level of evidence quality.

Chemotherapy-induced peripheral neuropathy in children and adolescent cancer patients

Brain cancer and leukemia are the most common cancers diagnosed in the pediatric population and are often treated with lifesaving chemotherapy. However, chemotherapy causes severe adverse effects and chemotherapy-induced peripheral neuropathy (CIPN) is a major dose-limiting and debilitating side effect. CIPN can greatly impair quality of life and increases morbidity of pediatric patients with cancer, with the accompanying symptoms frequently remaining underdiagnosed. Little is known about the incidence of CIPN, its impact on the pediatric population, and the underlying pathophysiological mechanisms, as most existing information stems from studies in animal models or adult cancer patients. Herein, we aim to provide an understanding of CIPN in the pediatric population and focus on the 6 main substance groups that frequently cause CIPN, namely the vinca alkaloids (vincristine), platinum-based antineoplastics (cisplatin, carboplatin and oxaliplatin), taxanes (paclitaxel and docetaxel), epothilones (ixabepilone), proteasome inhibitors (bortezomib) and immunomodulatory drugs (thalidomide). We discuss the clinical manifestations, assessments and diagnostic tools, as well as risk factors, pathophysiological processes and current pharmacological and non-pharmacological approaches for the prevention and treatment of CIPN.

Pharmacological and Nonpharmacological Management of Chemotherapy-Induced Peripheral Neuropathy: A Scoping Review of Randomized Controlled Trials

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a common and debilitating side effect of cancer treatment with no effective preventative strategy or definitive treatment. Purpose: To synthesize empiric literature from randomized controlled trials (RCTs) of pharmacological and nonpharmacological management of CIPN. Data Sources: Articles published between January 1, 2010, and February 28, 2021, were identified using keywords searching Medline, PubMed, CINAHL, Web of Science, Cochrane Library, and Embase. Study Selection: RCTs that recruited individuals who were post-chemotherapy and experienced persistent CIPN symptoms. Data Extraction and Synthesis: Three independent reviewers screened a total of 2023 abstracts. After screening, full-text review, and quality appraisal, 22 articles were included in this review. Data related to study design, participant characteristics, interventions, controls, outcome measures, and relevant findings were extracted from full texts. Descriptive quantitative summaries were calculated and narrative analysis was performed. Results: Of the 22 studies, 4 investigated pharmacologic treatments, 2 compared acupuncture to pharmacologic treatments, and 16 studies examined nonpharmacologic treatments. Pharmacologic studies reported mixed results with evidence of participant response varying by history of chemotherapeutic agent. Acupuncture, exercise/physical therapy, and neurofeedback appear to be effective treatments for CIPN. Evidence regarding biophysical agents and cognitive-behavioral therapy is equivocal. Scrambler therapy is not supported. Limitations: Studies included in this review share several limitations, including widely variable outcome measures, small and demographically homogenous samples, and nonstandardized treatment protocols. Conclusion: This scoping review summarized the current body of high-quality RCTs investigating treatment for CIPN. The majority of studies in this review reports benefits of pharmacologic and nonpharmacologic interventions, although management may require a multipronged approach and should be tailored to the individual. Clinical implications are proposed and suggestions made for future research include implementation of standardized intervention protocols, use of outcome measures representative of the spectrum of CIPN symptoms, and stratification by the chemotherapeutic agent.

Optimal outcome measures for assessing exercise and rehabilitation approaches in chemotherapy-induced peripheral-neurotoxicity: Systematic review and consensus expert opinion

INTRODUCTION

Chemotherapy-induced peripheral neurotoxicity (CIPN) remains a significant toxicity in cancer survivors without preventative strategies or rehabilitation. Exercise and physical activity-based interventions have demonstrated promise in reducing existing CIPN symptoms and potentially preventing toxicity, however there is a significant gap in evidence due to the lack of quality clinical trials and appropriate outcome measures.

AREAS COVERED

We systematically reviewed outcome measures in CIPN exercise and physical rehabilitation studies with expert panel consensus via the Peripheral Nerve Society Toxic Neuropathy Consortium to provide recommendations for future trials. Across 26 studies, 75 outcome measures were identified and grouped into 16 domains within three core areas - measures of manifestations of CIPN (e.g. symptoms/signs), measures of the impact of CIPN and other outcome measures.

EXPERT OPINION

This article provides a conceptual framework for CIPN outcome measures and highlights the need for definition of a core outcome measures set. The authors provide recommendations for CIPN exercise and physical rehabilitation trial design and outcome measure selection. The development of a core outcome measure set will be critical in the search for neuroprotective and treatment approaches to support cancer survivors and to address the gap in the identification of effective rehabilitation and treatment options for CIPN.

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.

Preventive effect of sensorimotor exercise and resistance training on chemotherapy-induced peripheral neuropathy: a randomised-controlled trial

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a common, unpleasant and usually long-lasting side effect of neurotoxic chemotherapeutic agents. This study aimed to investigate the preventive potential of sensorimotor- (SMT) and resistance training (RT) on CIPN.

METHODS

Patients (N = 170) were randomised to SMT, RT or usual care (UC). Both exercise groups trained 3×/week for a total of 105 min/week during neurotoxic chemotherapy (mean length: 20 weeks). Before and 3 weeks after neurotoxic chemotherapy, CIPN signs/symptoms were assessed via Total Neuropathy Score (TNSr; primary endpoint) and EORTC QLQ-CIPN15 questionnaire. In addition, balance (centre of pressure), muscle strength (isokinetic), quality of life (QoL, EORTC QLQ-C30) and relative chemotherapy dose intensity (RDI) were investigated. The follow-up period covered 6 months after the end of chemotherapy.

RESULTS

Intention-to-treat analyses (N = 159) revealed no differences regarding CIPN signs/symptoms. Exploratory per-protocol analyses (minimum training attendance rate 67%; N = 89) indicated that subjectively perceived sensory symptoms in the feet increased less during chemotherapy in the adherent exercisers (pooled group: SMT+RT) than in the UC group (-8.3 points (-16.1 to -0.4); P = 0.039, ES = 1.27). Furthermore, adherent exercisers received a higher RDI (96.6 ± 4.8 vs. 92.2 ± 9.4; P = 0.045), showed a better course of muscular strength (+20.8 Nm (11.2-30.4); P < 0.001, ES = 0.57) and QoL (+12.9 points (3.9-21.8); P = 0.005, ES = 0.64). During follow-up, CIPN signs/symptoms persisted in all groups.

CONCLUSIONS

This study demonstrates that SMT and/or RT alleviate subjectively perceived sensory CIPN symptoms in the feet and other clinically relevant cancer therapy-related outcomes, if an appropriate training stimulus is achieved.

CLINICAL TRIAL REGISTRATION

NCT02871284.

Type of exercise may influence postural adaptations in chemotherapy-induced peripheral neuropathy

OBJECTIVE

Traditional posturography measurements characterize postural instability in patients with chemotherapy-induced peripheral neuropathy (CIPN), while underlying postural control mechanisms remain unclear. Taking a model-based approach can yield insights into these mechanisms. This study's aim was to characterize the modifications in postural control of CIPN patients associated with exercise in relation to the postural behavior of healthy control participants (hCON) via an exploratory approach.

METHODS

Thirty-one CIPN patients were randomly assigned to two interventions (balance plus moderate endurance training vs. moderate endurance training only) and exercised twice per week over 12 weeks. Baseline data were compared to 36 matched hCONs. We recorded spontaneous sway and postural reactions to platform tilts using Optotrak and a Kistler force platform pre- and post-intervention. Data interpretation relied on a model-based parameter identification procedure.

RESULTS

Spontaneous sway amplitudes were larger and postural reactions smaller, with a relative phase advance, in our pre-intervention patients than the hCONs. Post-intervention, spontaneous sway, and postural reactions were reduced and the sensory-motor ratio larger in both groups, while the postural reaction timing differed between groups.

INTERPRETATION

The abnormally small postural reactions in CIPN patients before the intervention can be interpreted as the consequence of abnormally strong velocity control-a strategy modification that may serve as a prediction mechanism to compensate for the lack of timely and accurate proprioceptive signals. While both groups reduced postural sway and showed an adapted sensory-motor ratio post-intervention, the interventions seemed to trigger different velocity control strategies. This study emphasizes the need for taking a more differentiated perspective on intervention effects.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) number: DRKS00005419, prospectively registered on November 19, 2013.

Onco-Esthetics Dilemma: Is There a Role for Electrocosmetic-Medical Devices?

Objective

The primary aim of this review is to verify whether the warning against the use of electromedical instruments in the cosmetic professional or medical cancer patient settings is consistent with evident oncological risks supported by experimental in vitro/in vivo studies or anecdotal clinical reports, or any other reasonable statement.

Methods

MEDLINE, PubMed, Embase, AMED, Ovid, Cochrane Controlled Trials Register, and Google Scholar databases were electronically searched. Data relating to research design, sample population, type of electro-cosmetic devices used, were extracted.

Results

The search strategy identified 50 studies, 30 of which were potentially relevant.

Conclusions

Our research is in favor of moderate periodical use of cosmetic medical devices in patients bearing tumors, in any stage, like in healthy people. Special consideration is dedicated to massage, manipulation, and pressure delivery upon the cytoskeleton of cancer cells that has proven to be sensitive to mechanical stress at least in some specific locally relapsing cancers such as osteosarcoma.

Impact of whole-body vibration exercise on physical performance and bone turnover in patients with monoclonal gammopathy of undetermined significance

OBJECTIVE

Monoclonal Gammopathy of Undetermined Significance (MGUS) is a risk factor for reduced physical performance, osteoporosis, and fractures due to compromised musculoskeletal metabolism. In this condition it is unknown whether whole-body vibration (WBV) exercise favorably alters physical performance and bone metabolism.

METHODS

To evaluate the effect of three-months WBV exercise (30 min; 2x/week) including an optional three-month extension on physical performance, bone metabolism and bone mineral density. Endpoints included functional assessments, bone turnover markers and bone mineral density assessed by peripheral quantitative computed tomography of the tibia.

RESULTS

Fifteen MGUS patients (median age 62.0, nine female) completed the first three months of which ten completed the three-month extension. Measures of physical functioning including chair rise test, timed up and go and 6-minute walk test improved (p = 0.007; p = 0.009; p = 0.005) after three and six months of WBV exercise. Total tibial bone mineral density remained unaltered (p > 0.05). WBV exercise tended to increase levels of sclerostin (p = 0.093) with a transient increase in osteoclast resorption markers (N-terminal telopeptide of collagen type 1, tartrate resistant acid phosphatase 5b) after three months while Dickkopf-1 (p = 0.093), procollagen I N-terminal propeptide (p = 0.074) and total alkaline phosphatase (p = 0.016) appeared to decline. No exercise-related adverse events were reported.

CONCLUSION

WBV exercise in MGUS patients improves indicators of physical performance. Observed trends in bone turnover markers and changes in distal tibial bone mineral density may indicate a regulatory effect of WBV exercise on bone metabolism and warrants further evaluation by large scale studies.

Physiotherapy management of chemotherapy-induced peripheral neuropathy in Pretoria, South Africa

Background

The increase in newly diagnosed patients with cancer in South Africa and globally, may contribute to the increase in patients living with chemotherapy-induced peripheral neuropathy (CIPN). Chemotherapy-induced peripheral neuropathy negatively impacts on quality of life (QoL) during and post chemotherapy treatment. Physiotherapy management of CIPN helps patients to manage symptoms and improves function in activity- and participation-levels to ultimately improve QoL. However, little evidence exists regarding the type or combination of physiotherapy management strategies in South Africa.

Objectives

The purpose of our study was to determine how the symptoms of CIPN were managed by physiotherapists in Pretoria, South Africa.

Method

A quantitative, descriptive study design was used. Electronic questionnaires were distributed to physiotherapists who worked with cancer patients and who treated patients with CIPN.

Results

Physiotherapists used massage, proprioceptive neuromuscular facilitation, sensory integration, activities of daily living training, postural drainage, lifestyle modifications; Bobath-, breathing-, stability-, stretching-, strengthening- and endurance-exercises; electrical stimulation, thermal modalities, transcutaneous electrical nerve stimulation, soft tissue mobilisation; muscle energy-, positional- and Mulligan-techniques in the management of CIPN.

Conclusion

Cardiopulmonary therapy, therapeutic exercises, manual therapy and neuro-developmental techniques were used by physiotherapists in the management of CIPN. Almost half of the participants did not use electrotherapy techniques. Physiotherapy management strategies that are used in Pretoria are similar to published research.

Clinical implications

Physiotherapists in Pretoria are managing CIPN according to international practices. However, studies to determine the effectiveness of the management strategies in a South African context should be conducted. Alternative management strategies, based on the pathophysiology of CIPN, should be explored.

Keywords

physiotherapy; chemotherapy-induced peripheral neuropathy; intervention; management; cancer.

Mechanisms, Predictors, and Challenges in Assessing and Managing Painful Chemotherapy-Induced Peripheral Neuropathy

OBJECTIVE

To describe the known predictors and pathophysiological mechanisms of chronic painful chemotherapy-induced peripheral neuropathy (CIPN) in cancer survivors and the challenges in assessing and managing it.

DATA SOURCES

PubMed/Medline, CINAHL, Scopus, and PsycINFO.

CONCLUSION

The research on chronic painful CIPN is limited. Additional research is needed to identify the predictors and pathophysiological mechanisms of chronic painful CIPN to inform the development of assessment tools and management options for this painful and possibly debilitating condition.

IMPLICATIONS FOR NURSING PRACTICE

Recognition of the predictors of chronic painful CIPN and proactive CIPN assessment and palliative management are important steps in reducing its impact on physical function and quality of life.

Prevention and Management of Chemotherapy-Induced Polyneuropathy

Chemotherapy-induced peripheral neurotoxicity (CIPN) is a severe and common side effect caused by a variety of antineoplastic agents. Approximately 30-40% of patients treated with agents such as taxanes, vinca alkaloids, or platinum derivatives will develop CIPN. CIPN presents predominantly as a sensory axonal neuro(no)pathy with occasional motor and autonomic dysfunction exhibiting considerable variability of clinical symptoms ranging from mild tingling sensation to severe neuropathic pain. Typical symptoms include numbness ("minus symptom"), weakness, and abnormal gait as well as paresthesia and pain ("positive symptoms"). As CIPN symptoms potentially lead to long-term morbidity and can even aggravate after cessation of therapy, patients' quality of life can be tremendously affected. In view of improved breast cancer survival outcomes, the late effects of CIPN are an unmet need in these patients. Therefore, early detection and assessment of first symptoms is important to effectively prevent severe CIPN. Therapeutic options for patients with CIPN are still limited, and pharmacological treatment focuses primarily on reduction or relief of neuropathic pain. CIPN is usually acutely managed by dose reduction or discontinuation of causative chemotherapy, potentially compromising treatment outcome. Currently, there is no causative proven therapy for the prevention of CIPN.

Oncology nurses' knowledge, practice, and confidence toward chemotherapy-induced peripheral neuropathy in Jordan

Objectives:

To assess the knowledge, practice, and confidence of oncology nurses toward chemotherapy-induced peripheral neuropathy (CIPN) among patients with cancer in Jordan.

Methods:

Descriptive, and cross sectional study was conducted on a convenience sample of 148 Jordanian registered oncology nurses recruited from a Specialized Oncology Center in Jordan. Data collection took place in June, 2015. As a data collection tool, the assessment of oncology nurses’ knowledge and practice-revised questionnaire was used.

Results:

The mean CIPN knowledge score of 8.98/16 (SD=1.9) indicated that there were knowledge deficits regarding CIPN among Jordanian oncology nurses. Only 58.8% of the subjects indicated that CIPN assessment is necessary for their oncology practices, but the majority rated their CIPN assessment skills as inadequate. Neurologic physical assessment usually is not included in practices assessment. In addition, 57.1% believed that CIPN was a significant problem for patients and their families.

Conclusion:

There is a significant requirement to enhance the neurological assessment skills of oncology nurses and an efficient approach to CIPN assessment is demanded. Creating guidelines to manage and assess CIPN, and further investigations in different health institutions to generalize the results across Jordan are highly needed.

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.

Whole-Body Vibration Training Designed to Improve Functional Impairments After Pediatric Inpatient Anticancer Therapy: A Pilot Study

PURPOSE

To assess a whole-body vibration (WBV) intervention for children after cancer treatment.

METHODS

Eleven children after inpatient anticancer therapy participated in a 12-week supervised WBV intervention, which consisted of one 9- to 13-minute WBV session per week, with 5 to 9 minutes' overall vibration time. Feasibility was defined as the ability to participate in WBV training without reporting adverse events. The number of offered and completed training sessions, program acceptance, and measures of function were assessed.

RESULTS

Nine participants completed the WBV intervention without any WBV-related adverse events. The adherence rate was 87.96%. Only minor side effects were reported and there was general program acceptance. We found indications that WBV has positive effects on knee extensor strength and active ankle dorsiflexion range of motion.

CONCLUSIONS

WBV was feasible, safe, and well received among children after inpatient anticancer therapy. No health deteriorations were observed. Positive effects need to be confirmed in future trials.

Feasibility of whole body vibration during intensive chemotherapy in patients with hematological malignancies - a randomized controlled pilot study

BACKGROUND

Hospitalized cancer patients undergoing intensive or high-dose chemotherapy often experience a considerable decline in functional performance associated with the increased risk of adverse health events. Exercises, particularly resistance-based exercises that may counteract this decline are restricted by therapy-related side effects. Since whole body vibration (WBV) is known to efficiently stimulate the neuromuscular system without significantly raising blood pressure, we hypothesize that especially WBV is particularly feasible even during intensive or high-dose chemotherapy (primary endpoint) and thus induces beneficial functional adaptations.

METHODS

Twenty hospitalized patients with hematological malignancies scheduled for intensive or high-dose chemotherapy were randomly allocated to an intervention group (IG) undergoing WBV, or an active control group (CG) cycling. Feasibility was determined by comparing the IG's and CG's training compliance. Furthermore, to assess feasibility, WBV-induced changes in chemotherapy-related side effects, blood pressure, and heart rate immediately after exercising were documented. To assess patients' functional performance, we measured jump height (cm), the duration (sec) of performing the chair rising- (CRT) and timed-up-and-go test (TUG), maximum power output during jumping and CRT (watt/kg) as well as sway path (mm) during balance tasks.

RESULTS

Training compliance was similar between groups (IG: median 62%, range 39-77; CG: 67%, 58-100; p = 0.315). Moreover, we observed neither the IG's reported side effects worsening, nor any increase in blood pressure after WBV. IG's jump height (+ 2.3 cm, 95%CI 0.1-4.4, p = 0.028) and TUG performance (- 1.3 s, 95%CI -2.53 - -0.65, p = 0.027) improved significantly, while sway paths in semi-tandem stance were augmented after the intervention (eyes open: + 60 mm, 95%CI 2-236, p = 0.046; eyes closed: + 88 mm, 95%CI 49-214, p = 0.028). The CG's performances did not change over time. Maximum power output during CMJ and CRT and time during CRT did not change.

CONCLUSION

Our study is the first proving the feasibility of WBV during intensive/high-dose chemotherapy of hospitalized cancer patients. Additionally, WBV-induced neuromuscular adaptations resulted in functional benefits relevant to patients' autonomy. We believe that WBV can be implemented as an alternative training method during intensive chemotherapy, although the relative benefit compared to conventional resistance training requires more evaluation in future studies.

TRIAL REGISTRATION

German Register of Clinical Trials No.: DRKS00004338 , prospectively registered on 11/30/2012.

Whole body vibration exercise in the management of cancer therapy-related morbidities: A systematic review

The purpose of this systematic review was to investigate the effects of whole body vibration (WBV) exercise in the management of cancer therapy-related morbidities. The PubMED and PEDro databases were used to access publications published in English about the use of whole body vibration (WBV) exercises in cancer patients until February 22^nd 2017. The studies included were classified according to the level of evidence (LE) by the National Health and Medical Research Council Hierarchy of evidence and the methodological quality (MQ) by the PEDro scale. The four included studies (2 of them with "high" LE-II and MQ) were performed in patients with different types of cancer (i.e. breast, lung, prostate, solid or hematological), treated with WBV exercise to counteract the cancer therapy-related morbidities. The variables evaluated were muscle activity, subjective rate of perceived exertion, exercise capacity, muscle strength, quality of life, resting urinary incontinence and severity of peripheral neuropathy. Although WBV exercise appears to be a potential treatment procedure of cancer therapy-related morbidities, further additional studies are required to determine specific and tailored protocols to be used in the different stages of the disease.

Chemotherapy-induced peripheral neuropathy: a review of recent findings

PURPOSE OF REVIEW

Chemotherapy-induced peripheral neuropathy (CIPN) is a common, frequently chronic condition characterized by pain and decreased function. Given the growing number of cancer survivors and an increasing recognition of opioid therapy limitations, there is a need for critical analysis of the literature in directing an informed and thoughtful approach for the management of painful CIPN.

RECENT FINDINGS

A PubMed search for 'chemotherapy-induced peripheral neuropathy AND pain' identifies 259 publications between 1 January 2016 and 31 March 2017. Based on review of this literature, we aim to present a clinically relevant update of painful CIPN. Notably, the use of duloxetine as a first-line agent in treatment of CIPN is confirmed. Moreover, clinical trials focus on nonpharmacologic strategies for managing painful CIPN.

SUMMARY

Despite the volume of recent publications, there are limited preventive or therapeutic strategies for CIPN supported by high-level evidence. Duloxetine remains the only pharmacologic agent with demonstrated benefit; its clinical use should be routinely considered. Moving forward, nonopioid analgesic therapies will likely play an increasing role in CIPN treatment, but further research is necessary to confirm their utility. Promising therapies include vitamin B12 supplementation, physical therapy, and various forms of neuromodulation.

Results From a Pilot Study of Handheld Vibration: Exercise Intervention Reduces Upper-Limb Dysfunction and Fatigue in Breast Cancer Patients Undergoing Radiotherapy: VibBRa Study

Purpose:

Although there is evidence that breast cancer patients benefit from exercising during treatment, exercising during radiotherapy and especially the effects on upper-limb dysfunctions have been infrequently assessed. Therefore, we primarily aimed to confirm our interventions’ feasibility and secondarily aimed to affect upper-limb dysfunctions and fatigue.

Methods:

Twenty-two breast cancer patients scheduled for radiotherapy were allocated to an intervention (IG) or a passive control group (CG) as they preferred. IG exercised 3×/week during 6 weeks of radiotherapy: cycling endurance, handheld vibration, and balance training. We documented adverse events and training compliance (feasibility) and assessed the range of shoulder motion (ROM), isometric hand grip strength, vibration sense on the first metacarpophalangeal joint of the affected upper limb, and fatigue.

Results:

We observed no adverse events and a training compliance of 98 %. IG’s ROM improved significantly (abduction: 11°; 95% confidence interval [CI] 5 to 20; external rotation: 5°, 95% CI 0 to 10), as did the hand grip strength (1.6 kg, 95% CI −0.6 to 3.1), while CG’s ROM did not change. CG’s vibration sense worsened (−1.0 points, 95% CI −1.5 to −0.5), while IG’s remained stable. Changes in general fatigue levels between IG (−2.0 points, 95% CI −3.0 to −1.0) and CG (0.5 points, 95% CI −1.0 to 4.5) revealed significant differences (P = .008)

Conclusions:

Our intervention proved to be feasible and provides novel findings: it reduced fatigue levels and interestingly, handheld vibration exercises improved upper-limb function due to shoulder ROM, hand grip strength, and vibration sense.

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).