How to manage neuropathy during cancer treatment  

Tracy Eckett, Senior Physical Therapy Assistant Hi, I'm Tracy Eckett, senior physical therapy assistant at UT MD Anderson, and I primarily work with breast cancer patients. I'm here today with Dr. Salahadin Abdi, chair of Pain Medicine at UT MD Anderson. And this is the Cancerwise podcast. Dr. Abdi, thank you for joining me today.  

Salahadin Abdi, M.D., Chair, Pain Medicine Happy to be here.  

Tracy Eckett, Senior Physical Therapy Assistant In our roles at MD Anderson, we encounter patients that have developed neuropathy, and this can be very devastating to some of our patients' lives with their loss of the ability to walk, hold things in their hands, dress themselves and other activities of daily living. So, today we're going to talk about how to manage some of the effects of the neuropathy. Would you please explain what neuropathy is?  

Salahadin Abdi, M.D., Chair, Pain Medicine Yeah, absolutely. That's a very important question to begin with, really, in this case, neuropathy, what it really means and how it affects patient's quality of life, which we'll go into that shortly. So, neuropathy is defined as any type of nerve damage which results in abnormal function of that nerve.  

Salahadin Abdi, M.D., Chair, Pain Medicine So, for those who might be a little bit interested in the history of the word where it came from, it's really an ancient Greek word "neuros," meaning "nerve," and "pathia" or "pathos" meaning "injury, disease, or condition." So, if you put the two together, "neuropathy" means damage and conditional nerve damage specifically which results in abnormal function of the nerve.  

Tracy Eckett, Senior Physical Therapy Assistant Dr. Abdi, what are some of the symptoms of neuropathy?  

Salahadin Abdi, M.D., Chair, Pain Medicine Yes, very, very interesting. So, symptomwise, if we focus on chemo-induced peripheral neuropathy, typically patients present with peripheral, in this case, legs, feet, as well as hands, associated tingly sensation, pain sometimes, not a lot of times, but sometimes, as well as its effect on the motor function, fine motoric of hands, if the hands are involved, really, they are not able to hold a cup of tea, they are able to button their shirt. So, simple things which we take for granted, it's very, very difficult for patients who are affected with that neuropathy.   

Salahadin Abdi, M.D., Chair, Pain Medicine A lot of times, that neuropathy might start with toes and ascends upwards towards the legs, and subsequently, it might also, affect the hands and fingers, as I said. Unfortunately, occasionally, patients might have both hands and feet affected with that, and you could imagine how much their quality of life would be affected in those cases. So, typically they have a tingling sensation and pain. They have a burning sensation. They have electrical shocking sensation, intermittently coming on and off. And occasionally, I would say maybe about 25% of the cases, they might be very hypersensitive. You cannot even touch them. They can't touch anything because it's so sensitive. 

Salahadin Abdi, M.D., Chair, Pain Medicine They are not able to wear their socks, which they normally do, you know, normal shoes. They won't be able to do that. They won't be able to walk because of the numbness and the tingling. It really affects their quality of life quite significantly.  

Tracy Eckett, Senior Physical Therapy Assistant It does.  

Salahadin Abdi, M.D., Chair, Pain Medicine And that subsequently could also lead to depression. You know, if you are not able to do something which you have been doing for your life, you know, until you get that chemo treatment, it really affects your life. So, we as the providers, it's our job in collaboration with you guys, really, as a physical therapy department, we try to help them in many different ways. We'll go into the treatment options and then also, seek your help to give them an appropriate type of exercises and physical therapy management to improve their quality of life, to make them functional. The goal is never just to reduce the pain and the tingling sensation. The goal should be to make the more functional, so that they have a better quality of life.   

Tracy Eckett, Senior Physical Therapy Assistant Absolutely. What are some of the chemotherapies that can cause neuropathy?  

Salahadin Abdi, M.D., Chair, Pain Medicine Yeah, interestingly, almost all chemos induce. Obviously, there are certain criterias, why some patients might have just a small amount of symptoms compared to others. It depends on the age of the patients. In general, according to literature, we know that the elderly patients are more susceptible to get this chemo-induced peripheral neuropathy compared to the young generation. Also, the recovery time is much better or favorable to the younger generation compared to the elderly generation. Underlying other disease, you know, we have a number of patients who have already, you know vitamin deficiency or [...]. In addition to when they get any type of chemo, they are more susceptible to get chemo-induced peripheral neuropathy. But also, severity-wise, the amount of drug which they get is directly related to the severity of the disease, which they might have. So, there are many different factors which might contribute to this chemo-induced peripheral neuropathy. But in general, one could clearly say that any type of chemo could induce peripheral neuropathy. And that's also, very, very important to recognize as patients, but also, as providers, we need to be aware of that. We need ask patients if they have any type of symptom. That's very, very important, not only from providers' perspective, but also, patients need to express to their doctors. They shouldn't wait too long, because the earlier we intervene, like any other disease, the better chance of outcome we have. So, it's very important for the patients to understand and to talk to their doctors, you know, in advance about this possible risk associated with chemo.   

Tracy Eckett, Senior Physical Therapy Assistant Absolutely. I have found in my practice, the incidence of neuropathy, especially because I work with breast cancer patients, can be anywhere from 70 to 90 percent. And unfortunately, without intervention, sometimes it can become permanent. There is some information out there regarding cryotherapy or cold therapy. And basically, the cold therapy, as we know, will constrict the blood vessels. So, the patient, breast patient, woman does not want to lose all of her hair, has the option of putting a cold cap on her head. And again, like I said, it's not preventable entirely, but it can help them not lose about 50% of their hair. So, again, you do the cold cap during the infusion and helps prevent some of the hair loss. And it's the same concept with the vasoconstriction of the blood vessels when putting cold packs on the hands and the feet. Again, it doesn't prevent it entirely, but if we can mitigate the severity of the neuropathy, I think that would be super beneficial. And I tell my patients the point is just to make it cold.   

Salahadin Abdi, M.D., Chair, Pain Medicine Yeah, you are absolutely right. So, what you said about cooling, timing is important, when to cool, or when to try to cool. The reason why I say timing is important like anything else in life is that when you use the cooling which you mentioned during the infusion period, you'd like to have a vasoconstriction, less blood flow to the extremities so that the toxins do not approach that area of the extremity in that high concentration. That's the thinking behind that, and with the hope to be able to prevent it possibly or even just to make it less damage, you know. But during the later phase, after the infusion is over, after the peripheral neuropathy is well-established, a lot of patients, in fact, do better if they use heating rather than cooling. And the simple reason is that a number of patients feel very cold in general. So, they try to make as much as possible a warmth around the extremities, whether using gloves or warm socks and so on. Of course, every individual patient is different. So, that's why it's very important to communicate with the provider, the patients need to see a provider and talk with the provider, let the provider examine them and give them the different options what might be appropriate for that specific patient. It's not the same thing for every patient. Every patient is different.   

Tracy Eckett, Senior Physical Therapy Assistant They are. Very, very individualized care that we do here. What are some of the things that you do in your department to help with neuropathy?  

Salahadin Abdi, M.D., Chair, Pain Medicine There are patients who prefer medication approach and we have different categories of medications. So, whether they are opioids or non-opioids-related, a number of medications, typically we might use a category of medications such as anti-seizure medications, anti-depressive medications, a combination of both sometimes, anti-inflammatory medications sometimes, depending on the individual patient medication-wise. There are also a number of non-medication approach which we could utilize, quite successfully, in fact. Some of the newer, relatively newer options which we have in non-drug-related treatments are the so-called neuromodulations, basically meaning that we modulate or we change the way the abnormal nerves, which I said initially when I defined neuropathy, how we could modulate or change their functionality. In simple terms, how could we make them better functioned rather than continuing to have abnormal function of those damaged nerves? So, there are different approaches, invasive approach and non-invasive approach. I've been utilizing over the last few years, really, the so-called scrambler therapy, just like scrambled eggs. And the reason why it's called scrambled egg is that we try to scramble the information, which originates from the injured nerve, whether it's from hands or feet, to the brain, that's where everything, all the signals end up anyhow. And the brain interprets that signal as a painful sensation, normally. So, we try to scramble by using this device and treatment techniques to be able to retrain the brain to recognize normal signal rather than the abnormal, painful signal. And we've been doing it relatively successfully. Of course, not on 100% of patients, but I would say the majority of patients seem to get better within a short period of time and it doesn't have any side effects. There is no complication associated with that. The only maybe a little bit of downside of that treatment, the so-called scrambler treatment, is that it has to be done at least over five days. So, patients come every single day, Monday through Friday normally, to our pain clinic to get the treatment for 30 to 45 minutes on an average. So, it's investing five days a week, 45 minutes or so each day, which I think is worthwhile. We have a number of patients whom we took off their pain medications completely. We have number of patients on whom we at least reduce the amount of pain medication they require.  

Tracy Eckett, Senior Physical Therapy Assistant That's wonderful. Regarding the scrambler, is it patients who acutely have the neuropathy or can you see patients that, "Oh, I've had this for five years, is there help for me now?"  

Salahadin Abdi, M.D., Chair, Pain Medicine Absolutely. It's a very good question. It really doesn't matter as far as our success rate has been so far with scrambler therapy. I have a number of patients for X number of years of chemo. I also  had patients who just finished their chemo and then came to me because, you know, it's very unpredictable. Some patients do have the sensation that tingling sensation and neuropathy immediately

during the first cycle of their treatment. Others might have a little bit later on. So, fortunately, those patients who present to us could get the treatment early enough and get better result than the others. But, you know, the treatment does not rule out those who have a chronic disease not to get the treatments. So, we do have success with the other ones as well too. Yeah, it's really amazing. The good thing is it doesn't have side effects. So, what we do is we place the electrodes, if hands are involved, around the wrist area, and for feet, around the ankle area normally or above the ankle. So, what I tell patients is the first thing they feel is like a bee sting when it's put on the machine basically and turn on the machine. And afterwards, they just feel like a vibration-type of sensation coming and going, coming and going type of vibration sensation. Not painful at all. Now, the question which patients always ask me is that how long will that last? "I'm very happy now, but how long is this going to last? Is it going to come back?" And so on. Each individual's response is different, the same way like any other disease. But in general, those patients who do respond in the early treatment phase, they do seem to respond for about several months, I would say. And the good thing is if at all the pains come back, if at all, some patients might get another cycle of chemo treatment, who knows what, but no matter what the reason is, if the pain comes back, they could get a booster treatment. And that booster treatment doesn't necessarily have to be five days again. So, it could be a day depending on how much sensation, the tingling sensation or pain they might have. It could be two days. Again, each individual is different, but the good news is, I would say, on an average, several months relief.   

Tracy Eckett, Senior Physical Therapy Assistant Great.  

Salahadin Abdi, M.D., Chair, Pain Medicine That's really great. Keep in mind, we reduce their pain medication during that time, or even take them off, which also means that all the side effects associated with the pain medication is gone. So, patient's quality of life will be better. They are able to sleep better. They are able to be independent. You know, those who have got significant neuropathy, they can't do anything. You know, they can't make their own coffee, they can't go out to post if they need a signature to do. They can't sign anymore. They can't go to the bank. They're really dependent on somebody else. So, if they get the relief, some degree of relief, their quality of life certainly gets better and they become independent to some degree.   

Tracy Eckett, Senior Physical Therapy Assistant Absolutely. That is so, wonderful. I love learning about this.  

Salahadin Abdi, M.D., Chair, Pain Medicine It's really great.  

Tracy Eckett, Senior Physical Therapy Assistant From the department that I work in, another way to manage neuropathy is getting a referral from your physician for physical and occupational therapy. We evaluate the patient with their strength, their sensation, their reflexes, how they walk and also their balance. We have had a program going of teaching a specific type of massage for their lower legs, and feet, in between the toes, same things for the hands, below the elbows, down to the hands through between the fingers and also teaching them specific exercises that they can do. And following this program, we have had great success with that. Because it is like you said, if they can't feel their feet, they're not going to want to walk. And so, getting their sensation back and getting them stronger, getting the proprioception back in their feet just with those interventions has been helpful. The other interesting things is we've been able to put a special type of Kinesio tape in a particular fashion on the bottoms of the feet and the bottoms the hands. And I have had, like you with your scrambler, almost instantaneous results of patient Jane Doe can't feel her feet when she walks. And I put the tape on the bottom of her feet and she's like, "Oh my gosh, I can feel my feet." And so, she's able to do things like you discussed, her activities of daily living again. So, those have just been super helpful. But with any kind of physical therapy and occupational therapy, you have to continue to do those things at home, the massages, the exercises. A compliant patient makes a great patient. It makes a functional patient.   

Salahadin Abdi, M.D., Chair, Pain Medicine I tell my patients, it's not just three weeks you go there and that's it for the rest of your life. No, you have to do your work as well, too at home.  

Tracy Eckett, Senior Physical Therapy Assistant We work with the patient in physical and occupational therapy, and we will teach the patient and or their family members how to massage their hands and their feet. So, it's a basic, nice massage, not deep, and you can start just right below the elbow and just a massage, like so. You can spend five minutes on each extremity, massaging the palms of the hands, the back of the hands, each finger and also in between the fingers and the toes. Same with the lower leg, same type of pressure, just massaging from below the knee all the way down, around the ankle, bottom of the foot, top of the foot, around the toes, and between the toes as well.   

Salahadin Abdi, M.D., Chair, Pain Medicine Oh, that's great, I think, because as you said, it's easy to learn and they could do that at home. The only thing which I would emphasize to my patients about that is that they really have to do it religiously, not just once in a week or so, do it every day.  

Tracy Eckett, Senior Physical Therapy Assistant Home program is key.  

Salahadin Abdi, M.D., Chair, Pain Medicine So, it's very important to emphasize it. It's a simple thing, but helpful, right? That's the key. And we are truly very fortunate to have you guys, because we work collaboratively. It's not just one department working by itself in a

silo. It is a collaborative effort for the benefit of patients. And physical therapy, not only for neuropathy, for a lot of different types of pain, we really need to incorporate and utilize the opportunity that we have. One of the first questions I ask my patients with neuropathy is, have you done any type of physical therapy addressing this neuropathy issue at all or not? If the answer is no, then that's going to be one of the top priorities, part of our treatment regimen.  

Tracy Eckett, Senior Physical Therapy Assistant That's awesome. I know you, like, you spoke earlier about the importance of speaking up early. I don't want a patient to say, "Well, this is just what I have to deal with to go through my chemo." It's like, explaining to the patient, like you said, you must speak up and let your physician know if they're developing any sort of impaired sensation in their hands and their feet.  

Salahadin Abdi, M.D., Chair, Pain Medicine Absolutely, absolutely. We also ask providers who have to keep in mind, you know, patients could have, particularly patients on chemo, could have chemo brain. They might forget a number of things. Some of them are afraid to say about pain and neuropathy issues, to bring it to their physicians. But I think they have to have a free mind and be able to express what they have with their providers. And most importantly, if they can't do that for whatever reason, we should tell the patients, bring somebody with you, somebody who could advocate for you, family members, friends, or whoever that might be. And it's important for them to have somebody on their behalf if they can't advocate for themselves. So, talk to your providers. Very, very important. Providers cannot read minds. You have to tell them what you have so that we could help them.   

Tracy Eckett, Senior Physical Therapy Assistant Absolutely.  

Salahadin Abdi, M.D., Chair, Pain Medicine Very important. Another thing is also which we haven't mentioned really so far is even though, you know, scientifically, the literature is not that huge in the area of chemo-induced peripheral neuropathy, but the number of articles, the number of research articles which are coming out is increasing day by day, really. And even if you look at my favorite subject about the scrambler which I talked about quite a bit, there are more than 100 articles out there currently. Even though they are not big scientific articles, but the quality and the quantity of articles about this topic is increasing day by day. So, there is a light at the end of the tunnel and we are still working on that for the better life of our patient population.   

Tracy Eckett, Senior Physical Therapy Assistant Absolutely. That is wonderful. I've enjoyed this. Thank you for joining me today, Dr. Abdi. It was a great discussion.  

Salahadin Abdi, M.D., Chair, Pain Medicine My pleasure.  

Tracy Eckett, Senior Physical Therapy Assistant If you enjoyed this episode, don't forget to follow or subscribe on Apple Podcasts, Spotify, YouTube, or wherever you get your podcasts, and be sure to comment or review. For more information or to request an appointment at MD Anderson, call 1-877-632-6789 or visit MDAnderson.org. Thank you for listening to the Cancerwise podcast from UT MD Anderson.