Assessment tools for peripheral neuropathy in


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8/21/2018

Assessment tools for peripheral neuropathy in pediatric oncology patients receiving neurotoxic chemotherapy: a systematic review from the Children’s Oncology Group Suzanne Smolik, MSN, RN, CPNP, CPON Lesley Arland, MS, PA-C Mary Ann Hensley, RN,BSN,CNOR,ONC Debra Schissel, RN, CPON, CCRP Barbara Shepperd, RN, CPHON, CCRP Kristin Thomas, PT, DPT Cheryl Rodgers, PhD, RN, CPNP, CPON

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In Memoriam This systematic review would not have been possible without the guidance and assistance of our mentor, Cheryl Rodgers, PhD, RN, CPNP, CPON.

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 The authors have no financial interests to disclose.

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Objectives  At the conclusion of this presentation, attendees will be able to Explain 2 different assessment tools used to identify peripheral neuropathy ♦ Discuss use and limitations of these tools ♦ Summarize current evidence related to assessment of peripheral neuropathy in pediatric oncology patients receiving neurotoxic chemotherapy ♦

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Introduction  Vincristine ♦ ♦

Mainstay chemotherapy in pediatric cancer protocols May cause peripheral neuropathy and muscle strength loss, resulting in impaired gait, reduced endurance, and limitations in fine motor skills (Gilchrist, 2012)

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Introduction  Systematic review of chemotherapy induced peripheral neuropathy (CIPN) by Kandula and colleagues (2016) found that vincristine-related neurotoxicity was reported in 32 (52%) of the 61 studies  A recent study found most CIPN resolves within three months after completion of chemotherapy; however, some symptoms may persist, especially symptoms caused by vincristine (Loprinzi, 2017 and Varedi, 2018)

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Assessment Tools  CTCAE v3.0/v4.0  Ped-m TNS (Pediatric- Modified Total Neuropathy Scale)  TNS-PV (Total Neuropathy Scale – Pediatric Version)  FACES Pain Scale  Nerve Conduction Study  Neurological Exam

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Assessment Tools  Current Perception Threshold (CPT)  Tactile Perception Threshold (TPT)  Vibration Perception Threshold (VPT)

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Systematic review  No current assessment tool used by everyone  Standardized assessment would enable better tracking of outcomes across locations as well as create common language for CIPN  Properly assessing and identifying peripheral neuropathy, which can greatly impact quality of life, is the first step to properly treating and managing the side effect.  Regular assessment may allow for earlier identification of problems and decrease long-term effects 9

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PICOT question  In pediatric oncology patients receiving Vincristine, what assessment tools best evaluate early onset and progression of peripheral neuropathy?

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Data Collection  Databases ♦

PubMed • (Peripheral Neuropathy) AND (Pediatric) AND (Assessment) • 129 articles; 3 included



CINHAHL • peripheral neuropathy, assessment, pediatric • 6 articles; 1 included



Cochrane • (Peripheral Neuropathy) AND (Pediatric) AND (Assessment) • 5 articles; none included



National Guidelines Clearinghouse • Peripheral neuropathy • 3 guidelines; none included

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Data Collection  Lavoie Smith ♦ ♦

Peripheral Neuropathy 37 articles, 2 included (2 duplicate)

 Gilchrist ♦ ♦

Peripheral Neuropathy 16 articles, 2 included

 Hand searching ♦

2 articles

 Total Yield ♦

8 articles 12

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PRISMA Diagram

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Evidence Appraisal & Synthesis  AGREE II Instrument (Appraisal of Guidelines for Research and Evaluation)  GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) tool for collective evidence evaluation  Evidence Strength: Strong, Weak  Evidence Quality: High, Moderate, Low, Very Low

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Summary and Implications for practice  Formal PT assessment  Age for use of the TNS-PV scale  Subjective symptoms

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Formal PT assessment  Lavoie Smith and colleagues (2013) developed two versions of the TNS-PV scale - an original version (version A) to evaluate lower or upper extremity symptoms - and an alternative version (version B) to score lower and upper extremity symptoms by a trained evaluator (Lavoie Smith et al., 2013)

 An item analysis showed no statistical difference between versions A and B (Lavoie Smith et al., 2013)

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Formal PT assessment  Recommendation: There is a strong recommendation that all pediatric patients receiving vincristine should receive a formal assessment for peripheral neuropathy

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Age for TNS-PV scale  On the TNS-PV; vibration and temperature could not be measured in 87% of the children ≤ 3 years of age and numbness, paresthesia, and neuropathic pain could not be measured in 48% of 3 y/o pts (Lavoie Smith et al., 2013)  91% of all children were cooperative for the reflex testing and 78% of all children participated in the strength testing (Lavoie Smith et al., 2013)  All of the items on the TNS-PV were attainable in children ≥ 6 years of age (Lavoie Smith et al., 2013)

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Age for TNS-PV scale  Recommendation: There is a strong recommendation that the ped-m TNS or TNS-PV should be used for the assessment of vincristine induced peripheral neuropathy in children ≥ 6 years of age

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Subjective symptoms  An evaluation of 1539 assessments among 128 children receiving vincristine found 44% of children reported pain on the subjective symptom item but 78% had peripheral neuropathy (Lavoie Smith et al., 2013)

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Subjective Symptoms  Recommendation: There is a strong recommendation against the use of subjective symptoms alone to assess for peripheral neuropathy in children receiving vincristine

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Limitations  Limited literature in pediatrics  Small sample sizes  All articles-descriptive design

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Future Research  Determine usability and reliability in the ped-m TNS and TNS-PV in children <6 years old  Determine whether the cumulative dose of vincristine has an impact on severity of CIPN

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Acknowledgements  The authors would like to recognize Cory Beebe, MS, in the Musculoskeletal Research Center at Children’s Hospital Colorado for his assistance with the literature search.  This study was supported by the National Cancer Institute/National Clinical Trials Network Group Operations Center Grant (U10CA180886; PIAdamson).

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References Ackerley, R., Carlsson, I., Wester, H., Olausson, H., & Backlund & Wasling, H. (2014). Touch perceptions across skin sites: differences between sensitivity, direction discrimination and pleasantness. Frontiers in Behavioral Neuroscience, 8, 54 Biedrzycki , B.A. (2015). Peripheral neuropathy. In C.G. Brown (ed): A Guide to Oncology Symptom Management, 2nd edition. Pittsburgh, PA: ONS Publishing Division Dueck, A. C., Mendoza, T. R., Mitchell, S. A., Reeve, B. B., Castro, K. M Rogak, L. J., ... Li, Y. (2015). Validity and reliability of the US National Cancer Institute’s patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE). JAMA Oncology, 1(8), 1051-1059 Garrard, J. (2014). Health Sciences Literature Review Made Easy: The Matrix Method, 4th edition. Boston: Jones & Bartlett Gaudreault, F., Drolet, P., Fallaha, M., & Varin, F. (2015). The reliability of the current perception threshold in volunteers and its applicability in a clinical setting. Anesthesia & Analgesia, 120(3), 678-683 Gilchrist, L. (2012). Chemotherapy-induced peripheral neuropathy in pediatric cancer patients. Seminars in Pediatric Neurology, 12, 1071-9091 Gilchrist, L. S., Marais, L., & Tanner, L. (2014). Comparison of two chemotherapy-induced peripheral neuropathy measurement approaches in children. Supportive Care in Cancer, 22(2), 359-366 Gilchrist, L.S & Tanner, L. (2013). The pediatric modified total neuropathy score: a reliable and valid measure of chemotherapyinduced peripheral neuropathy in children with non-CNS cancers. Support Care Cancer, 21, 847-856 Gilchrist, L. S., Tanner, L., & Hooke, M. C. (2009). Measuring chemotherapy-Induced Peripheral Neuropathy in Children: Development of the Ped-m TNS and Pilot Study Results. Rehabilitation Oncology, 27(3), 7-15 Guyatt, G., Oxman, A.D., Akl, E.A., Kunz, R,, Vist, G., Brozek, J., … Schünemann, H.J. (2011). GRADE guidelines: 1. IntroductionGRADE evidence profiles and summary of findings tables. Journal of Clinical Epidemiology, 64(4), 383-394. Nursing, 14(1), 9-17 Halonen, P. (1986). Quantitative vibration perception thresholds in healthy subjects of working age. European Journal of Applied Physiology and Occupational Physiology, 54(6), 647-655

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References Holiner, I., Haslinger, V., Lütschg, J., Müller, G., Barbarini, D.S., Fussenegger, J., …. Simma, B. (2013). Validity of the neurological examination in diagnosing diabetic peripheral neuropathy. Pediatric Neurology, 49(3), 171-177 Hudson, M.M., Ness, K.K., Gurney J.G., Mulrooney, D.A., Chemaitilly, W., Krull, K.R., ... Robinson, L.L. (2013). Clinical ascertainment of health outcomes among adults treated for childhood cancer. JAMA, 309(22), 2371-2381 Kandula, T., Park, S.B., Cohn, R.J., Krishnan, A.V. & Farrer, M.A. (2016). Pediatric chemotherapy induced peripheral neuropathy: A systematic review of the current knowledge. Cancer Treatment Reviews, 50, 118-128 Langholz, B., Skolnik, J.M., Barrett, J.S., Renbarger, J., Seibel, N.L., Zajicek, A. & Arndt, C.A. (2011). Dactinomycin and vincristine toxicity in the treatment of childhood cancer: A retrospective study from the Children’s Oncology Group. Pediatric Blood & Cancer, 57(2), 252-257 Lavoie Smith, E.M., Li, L., Chiang, C.W., Thomas, K., Hitchinson, R.J., Wells, E.M., ... Renbarger, J. (2015). Patterns and severity of vincristine-induced neuropathy in children with acute lymphoblastic leukemia. Journal of the Peripheral Nervous System, 20(1), 37-46 Lavoie Smith, E.M., Li, L., Hutchinson, R.J., Ho, R., Burnette, W.B., Wells, E., … Renbarger, J. (2013). Measuring vincristineinduced peripheral neuropathy in children with acute lymphoblastic leukemia. Cancer Nursing, 36(5), E49-E60 Liveson, JA. (1992). Laboratory Reference for Clinical Neurophysiology. New York: Oxford University Press Loprinzi, C.L. (2017). Prevention and treatment of chemotherapy-induced peripheral neuropathy. In D.M.F. Zavarese (Ed), UpToDate. Retrieved from http://www.uptodate.com/home/index.html Lv, S-l., Fang, D., Hu, J., Huang, B., Zou, R., Wang, F-Y.,& Zhao, H-Q. (2015). Assessment of peripheral neuropathy using measurement of the current perception threshold with the neurometer in patients with type 1 diabetes mellitus. Diabetes Research and Clinical Practice, 109(1), 130-134 Nelson, D., Mah, J.K., Adams, C., Hiu, S., Crawford, S., Darwish, H.,.... Pacoud, D. (2006). Comparison of conventional and nonInvasive techniques for the early identification of diabetic neuropathy in children and adolescents with type 1 diabetes. Pediatric Diabetes, 7, 305-310 Varedi, M., Lu, L., Howell, C., Partin, R., Hudson, M., & Pui, C. et al. (2018). Peripheral Neuropathy, Sensory Processing, and Balance in Survivors of Acute Lymphoblastic Leukemia. Journal Of Clinical Oncology, 36. Wong, D., & Baker, C. (1988). Pain in children: Comparison of assessment scales. Pediatric Nursing, 14(1), 9-17

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Questions?

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