Saturday, 26 May 2018

Practical And Specific Exercises For Neuropathy Patients

Today's post from foundationforpn.org (see link below) provides us with specific exercises for people living with neuropathy and that's very valuable for those suffering from nerve pain. We read countless articles that tell us we must exercise, no matter what but rarely do we see a list of practical exercises especially designed for neuropathy patients. As a result, we can start to build up an exercise regime for ourselves, confident in the knowledge that we're doing the right thing and not causing ourselves even more damage. Nevertheless, if it's possible, working in conjunction with a doctor or properly qualified physiotherapist would be the best of all possible worlds but for most people, this isn't an option, so using this post as a basis would be a good beginning.
 

Exercise + Physical Therapy For Neuropathy
foundationforpn.org 2018

Research has shown that strengthening exercises for peripheral neuropathy moderately improve muscle strength in people with PN. In addition, exercises to help peripheral neuropathy, when done regularly, may reduce neuropathic pain and can help control blood sugar levels. A comprehensive physical activity routine includes four kinds of activities:


Aerobic Exercise
Flexibility Exercise
Strength Training Exercise
Balance Exercise

Refer to a physical or occupational therapist, or a healthcare provider, regarding an exercise program that’s right for you.

Physical Therapy


Physical therapy may be helpful in maintaining strength, mobility, and function regardless of the underlying cause of Peripheral Neuropathy (PN). Patients with diabetic neuropathy may also benefit from physical therapy, however, diabetic neuropathy patients must also tightly control their blood sugar levels to prevent major fluctuations.
The objectives of physical therapy include:
  • Maintaining and improve functions via a range of motion – passive range of motion exercises consist of progressive stretching and self-stretches
  • Strengthening muscles – this includes exercising against increasing resistance, use of weights, and isometric exercise
  • Balance training provides stability and prevents falls
  • Physical therapists can also recommend braces and/or splints to enhance balance and posture
  • Splinting is often used in the treatment of compression mononeuropathies, such as carpal tunnel syndrome
  Occupational Therapy

Occupational therapy is instrumental in helping a patient cope with the functional, vocational, and social impact of peripheral neuropathy by:
Improving sensory-motor skills
Teaching the patient to avoid exposure to environmental or industrial toxins
Teaching self-care activities
Teaching the patient safety issues, (e.g., paying more attention to the terrain when walking since falling or tripping may pose a risk for patients with PN)
Teaching the patient to pay attention to issues which involve automatic functions (e.g., learning how to change positions smoothly to avoid a sudden drop in blood pressure and the risk of falling)

Aerobic Exercise

Increases your heart rate, works your muscles, and raises your breathing rate. For most people, it’s best to aim for a total of about 30 minutes a day, between 3-5 days a week. If you haven’t been very active recently, you can start out with 5 or 10 minutes a day and work up to more time each week. Or split up your activity for the day — try a 10-minute walk after each meal.

Here are some examples of aerobic exercise:
Take a brisk walk (outside or inside on a treadmill)
Take a low-impact aerobics class
Swim or do water aerobic exercises
Stationary bicycle indoors

Flexibility Exercises


Flexibility exercises, also called stretching, help keep your joints flexible and reduce your chances of injury during other activities. Gentle stretching for 5 to 10 minutes helps your body warm up and get ready for aerobic activities such as walking or swimming. Here are some flexibility exercises you can do at home.

Check with your physician before beginning any exercise program.




Calf Stretch

Place one leg far behind you with the toe pointed slightly inward. Take a large step forward with the opposite foot. With the front knee slightly bent lean forward keeping your back heel on the floor. You should feel a muscle stretch in the calf of your back leg.

Hold: 15-20 seconds on each leg
Repeat: 3 repetitions each leg/2 times a day. 




Seated Hamstring Stretch

Sitting on the front half of a firm chair, place one leg out straight with the foot pointing up. Bend the opposite knee so that your foot is flat on the floor. Center your chest over the straight leg, and slowly straighten your back until you feel a muscle stretch in the back of your leg.

Hold: 15-20 seconds on each leg
Repeat: 3 repetitions each leg/ 2 times a day.


Plantarfascia Stretch

While facing a door frame, place your heel as close to the door frame as possible. Slowly lean forward, allowing your heel to slide back as your toes extend upward. To increase the stretch, bend the front knee toward the door frame. You should feel a muscle stretch in the bottom of your foot and along your heel cord.

Hold: 15-20 seconds
Repeat: 3 repetitions each leg/2 times a day.

Strength Training

Strength training exercises help to make the muscles stronger and more injury resistant. It can help you regain lost strength in your muscles through constant training routines. Here are some strength training exercises you can do at home.

Check with your physician before beginning any exercise program.


Kitchen Counter Calf Raises

While standing at the kitchen counter, place two finger tips on the counter. Stand on one foot lifting the other heel off the floor, standing on your toes (as you strengthen your muscles, try to alternate your heels as shown in the picture below). Slowly lower yourself to the floor and repeat. Once you are on your toes control your lowering Do not just drop down to the floor.

Repeat: 10-15 times
2 repetitions on each leg /2 times a day.


Chair Squat

Using a firm chair with armrests, position your feet in a split stance with one foot at the base of the chair and the other foot placed comfortably in front and slightly out to the side. Slowly transfer your weight forward until your legs are supporting your body weight. Slowly press up with your legs to standing. To lower yourself, slowly reach for the chair with your hips. Touch the chair with your hips and press back up for your next repetition. Do not “plop” in chair or rest in between repetitions.

Repeat: 10 -15 times
2 Repetitions/2 times a day.




Seated Dorsiflexion

While seating on the front half of a chair place both feet flat on the floor. Gradually pull the toes and ankle up as high as you can. Slowly let them down. To make this exercise more challenging position your feet closer to your body.

Repeat: 10-15 times
3 repetitions/2 times a day.

Balance

Keeping your balance system healthy is especially important if you have problems due to illness, such as joint pain, weakness or dizziness. Balance training can help you get back to normal, and overcome feelings of stiffness or unsteadiness. Balance, in particular, is emerging as an important element for the elderly. Older muscles are smaller and slower and respond less efficiently when you need to brace yourselves, making you more vulnerable to falls.


Kitchen Counter Calf Raises

While standing at the kitchen counter, place two finger tips on the counter. Stand on one foot lifting the other heel off the floor, standing on your toes (as you strengthen your muscles, try to alternate your heels as shown in the picture below). Slowly lower yourself to the floor and repeat. Once you are on your toes control your lowering Do not just drop down to the floor.

Repeat: 10-15 times
2 repetitions on each leg /2 times a day.




Hip Flexion

Hold table or chair with one hand, then one fingertip, then no hands; then do exercise with eyes closed, if steady. Stand straight: holding onto table or chair for balance. Slowly bend one knee toward chest, without bending waist or hips. Hold position for 5-10 seconds. Slowly lower leg all the way down. Repeat with other leg.

Hold: 5-10 seconds
Repeat: 2 repetitions on each leg/2 times a day.


Hip Extension

Hold chair or table with one hand, then one fingertip, then no hands; then do exercise with eyes closed, if steady. Stand 12 to 18 inches from chair or table. Bend at hips; hold onto chair or table. Slowly lift one leg straight backwards. Hold position for 5-10 sections. Slowly lower leg and repeat with other leg.

Hold: 5-10 seconds
Repeat: 2 repetitions on each leg /2 times a day


Side Leg Raise

Hold chair or table with one hand, then one fingertip, then no hands; then do exercise with eyes closed, if steady. Stand straight, directly behind chair or table, feet slightly apart. Hold chair or table for balance. Slowly lift one leg to side, 6-12 inches. Slowly lower leg and repeat with other leg. Your back and knees are straight throughout exercise.

Hold: 5-10 seconds
Repeat: 2 repetitions on each leg/2 times a day

https://www.foundationforpn.org/living-well/lifestyle/exercise-and-physical-therapy/

Friday, 25 May 2018

Why Are You Suffering From Burning Sensations?

Today's post from medicalnewstoday.com (see link below) addresses just one particular symptom of neuropathy but also one associated with many other problems...and that is diagnosing a burning sensation. Many people are confused by regular or consistent burning sensations. Not only are they painful and irritating, they are difficult to diagnose. For people living with neuropathy, or thinking they may be beginning neuropathic symptoms, it's important to rule out as many alternatives as possible. Of course, a burning sensation is a nerve response to a particular stimulation, so could always be described as being neuropathic but identifying the stimulation that causes the burning feeling will help your doctor identify the cause. This thorough article looks at all forms of burning and its potential causes and helps steer you along the right path, so you can work in tandem with your doctor in finding the cause and establishing the right treatment. Of course, if you're an experienced neuropathy patient, you'll know all about this, especially in your feet, legs and hands but burning sensations can also arise from a variety of situations - this article helps sort out the wheat from the chaff.

What can cause a burning sensation?
Last reviewed Tue 22 May 2018 By Zawn Villines
Reviewed by Nancy Moyer, MD


Causes
When to see a doctor
Treatment
Outlook 


A burning sensation can affect any part of the body. It may feel like pins and needles, heat, or a sharp, prickly pain. A wide variety of conditions can cause it, so it is important to seek medical advice and receive a correct diagnosis.

In this article, we look at the causes of burning sensations, when to see a doctor, and what treatments are available.
Causes of burning sensations


A burning sensation can occur anywhere on the body.


The location of the sensation can give a good indication of its cause. For example, a burning feeling in the muscles may be the result of an injury, while a burning sensation on the skin is likely the result of having come into contact with an allergen or an irritant, such as poison ivy.

Below are some of the most common locations of burning sensations and possible underlying causes:

While urinating


Feeling pain or a burning sensation while urinating is often a sign of a urinary tract infection (UTI). UTIs are much more common in women, and other symptoms can include a fever and a strong, continual urge to urinate.

Infections can affect the bladder, kidneys, or urethra. If left untreated, an infection can spread to other areas of the body. It can also harm the kidneys, and anyone who suspects that they have a UTI should see a doctor. UTIs are usually treated with antibiotics.

The following can also cause a burning sensation during urination:
sexually transmitted infections (STIs)
prostatitis, which refers to inflammation of the prostate
a physical injury to the urethra or surrounding tissue — often the result of shaving, sexual intercourse, or friction from clothing

Skin

Throughout the day, the skin comes into contact with a range of possible irritants. The following sources of irritation can lead to a burning sensation:
sunburn
plants that sting or cause a rash, such as nettles, poison ivy, or poison sumac
insect bites and stings, such as from wasps, bees, and spiders
allergic reactions to lotions, perfumes, detergents, or other substances that come into contact with the skin
very dry skin, particularly during the winter months
conditions such as eczema
anxiety or stress, particularly if a person is worried about skin conditions
nerve damage resulting from degenerative conditions such as multiple sclerosis

An intense burning sensation on the skin can also be caused by cellulitis. Cellulitis is a bacterial infection of the deepest layers of skin. It is treated with antibiotics.

Cellulitis can spread quickly, so it is important to receive treatment right away. See a doctor if a burning sensation is accompanied by:
fever
swelling, heat, or redness of the skin
swollen and painful glands

Hands and feet


A burning sensation in the hands and feet is often caused by one of the skin issues mentioned in the previous section.

However, burning in the fingers or toes could be a symptom of nerve damage. The medical community refers to this as peripheral neuropathy.

Up to 50 percent of people with diabetes may have peripheral neuropathy. A person with diabetes should speak with a doctor if they experience any of the following in the hands or feet:


pain
burning
tingling
numbness
weakness

Some other medical problems that may cause peripheral neuropathy include: 


multiple sclerosis
several infections, such as shingles and HIV
injuries and accidents
vitamin deficiencies, such as a lack of vitamin B12
kidney and liver disease
cancer

Raynaud's phenomenon can also cause a burning sensation in the hands and feet. It causes the small arteries in these extremities to spasm and close when exposed to the cold. Consequently, the fingers and toes receive less blood. They can turn white, and a person may feel a burning or stinging sensation, as well as numbness.

This condition can similarly affect the nose, lips, and ears. Symptoms disappear when a person warms themselves, increasing blood flow. 



Five home remedies for UTIs
Learn about the causes of urinary tract infections and five home remedies.
Read now


Muscles 

 


The feeling of burning in the muscles after working out is typically due to the release of lactic acid.

A person may feel a burning sensation in certain muscles when lifting weights or doing other strenuous exercises. This is typically due to the release of lactic acid.

A person may also feel this when they try a new exercise or start exercising more often. The soreness and burning sensation may be delayed. These symptoms are usually mild and tend to go away after a few days.

An intense burning sensation may indicate a muscle injury, such as a sprain or strain. If this feeling does not get better over time or spreads to several muscles, a person may have a chronic condition, such as fibromyalgia.

Other causes of a burning sensation in the muscles include:
arthritis
myofascial pain syndrome
a herniated disc in the spine

Mouth or throat


A burning sensation in the throat is often the result of an infection, such as strep throat. A person with strep throat may feel worse pain when talking, and the area may feel raw and scratchy. Strep throat is often accompanied by fever, chills, and other cold- or flu-like symptoms.

Strep throat is common in children, but relatively uncommon in adults.

Acid reflux can also cause a burning sensation in the throat. The sensation may be intermittent, but it tends to follow an acidic meal. People with acid reflux may also experience a feeling of burning in the chest, belching, and stomach discomfort.

Burning sensations in the mouth and gums are often the result of irritation caused by:
gum disease
vigorous tooth brushing
acidic foods

Canker sores can also cause this feeling. They are small, red or white sores that often appear on the lips or tongue. They can be quite painful but typically go away on their own after several days.

Genitals

A burning sensation in or around the genitals can result from skin irritation, such as that caused by getting soap in the vagina.

Tiny wounds caused by shaving or sexual intercourse can also lead to a temporary feeling of burning.

Infections are often responsible for a burning sensation in the genitals. Yeast infections and bacterial vaginosis commonly lead to a feeling of burning, itchiness, and unusual discharge, for example, and bacterial vaginosis can also cause a fishy vaginal odor.

Genital burning can also result from a wide range of STIs.


When to see a doctor 

 


A person should contact a doctor within 24 hours if they have a rapidly spreading rash.

It is usually safe to wait for a few days and see whether the sensation goes away. See a doctor if the feeling of burning persists.

Contact a doctor within 24 hours if any of the following symptoms occur:


a rapidly spreading rash
a fever
an intense burning sensation during urination
a burning sensation following a physical injury
other worrisome symptoms, such as bloody diarrhea or vomiting

Also, see a doctor if a burning sensation: 


recurs
is associated with a chronic illness, such as liver failure or diabetes
gets worse in response to medication 


Treatment

Treatment will depend on the cause. For example, many STIs and other infections can be eliminated with antibiotics.

When no cure exists, treatment will involve managing symptoms. Fibromyalgia, for instance, remains poorly understood and difficult to treat. A doctor will develop a plan to alleviate pain and other symptoms.

Work a doctor to find a treatment that works, and report any negative reactions to medication. If symptoms do not improve, ask about other treatment options. 


Outlook

A burning sensation is often a temporary annoyance that disappears on its own. Rashes typically clear up in a few days, and canker sores rarely require medical treatment. Speak with a doctor if symptoms grow worse or last longer than expected.

Anyone who suspects that they have an infection, such as cellulitis or a UTI, should see a doctor as soon as possible. These can spread and become more severe if left untreated.

https://www.medicalnewstoday.com/articles/321885.php

Thursday, 24 May 2018

Simple Nutritional Advice For Neuropathy Patients, Yet So Difficult To Follow

Today's post from ntc.lluh.org (see link below) is from a university neuropathic health centre and contains simple nutritional advice for people with nerve damage and those who may be prone to it. The advice is simple and seems relatively easy to follow up on but the problem is that so many people have such great difficulties in implementing it! Unfortunately, 21st century eating habits are so attractive to the palate that while they may be bad for you, they're very difficult to let go or change. Yet your nervous system will thank you for changing your diet. Everything in moderation they say, so don't give up the goodies, just modify or reduce them and include the suggestions in this article to help restore balance in your body. There's nothing new in this article's advice but it seems to be a mountain to climb for many neuropathy patients. Comfort food is a great temptress when you're in pain but if you consider that a dietary change may reduce your pain, a little self-discipline should go a long way.


Neuropathy Nutrition 101 
02 May 2018 By Dr. Mark Bussell

It’s not every day that you think about the food you put in. It’s easier to not care about certain ingredients or daily serving sizes when the stomach is calling. However, this relaxed way of thinking needs to change if the body has any hope of feeling good.

Good nutrition plays an integral role in how you fight off certain illness, recover faster and ward off unnecessary pain.

It’s time to think about what you put in your body and how it helps or hurts you more than you think. Here is a look at healthy nutrition habits to incorporate for a more well-balanced and pain-free life. 


Consume heart-healthy fats

It can be a struggle for many patients living with diabetic nerve pain to maintain a healthy cholesterol level. The goal is to aim for a well-balanced diet that is rich in heart-healthy fats such as olive oil, canola oil, nuts and seeds. 


Take in vitamin B12

Neuropathy patients can often find themselves with lower levels of B12. It’s important to eat foods high in B12, such as eggs, milk or cheese. Feel free to talk with a physician about B12 supplements as an added dose of support. A physician may recommend a blood test to check B12 level for a healthy diagnosis. 


Go gluten-free

How often have you heard this before? I’m sure far too many, but, the truth is maintaining a gluten-free diet is healthy and ideal to reducing nerve pain. Gluten can affect the stomach, skin and even the brain. It can be difficult to eat foods with gluten (i.e. pastas, breads, oats). Aim to eat plenty of legumes, eggs, vegetables, nuts, and fruits to get your daily dose of nutrients. 


Eat fruits and vegetables

Fill your plate with as many bright colors and leafy greens to satisfy your hunger craving. Fruits and vegetables are rich in antioxidants, vitamins and minerals. They provide a nutritious balance to fight nerve pain and even control diabetic symptoms. Aim to eat at least five servings of fruits and vegetables a day.


Drink lots of water

Water should be a staple in any diet, and even more so for those looking to reduce nerve pain. It’s critical to stay hydrated throughout the day to reduce inflammation and avoid triggering pain receptors. Aim to drink eight 8-oz. of water each day.

Talk with your doctor before starting any new diet. It’s important to maintain a healthy and well-balanced diet that not only improves your nerve pain, but keeps you going throughout the day.

https://ntc.lluh.org/blog/neuropathy-nutrition-101

Wednesday, 23 May 2018

A Few Ironic Smiles To Help Live With Chronic Nerve Pain

Today's post from themighty.com (see link below) looks at the brighter side of not being able to work and living with a disease like neuropathy and yet subtly brings across a more serious message too. It concerns attitudes towards being disabled by illness - both patients' attitudes and the attitudes (and sometimes downright hostility) of those around them. Hopefully, it'll make you smile even if you may not want to laugh out loud and goodness knows, if you're living with neuropathy, you need a smile now and then!


14 Memes That Nail What It's Like to Be Unable to Work Due to Illness
21st May 2018 Paige Wyant Staff

For many of those in the chronic illness/disability community, health conditions prevent them from being able to work. While it can absolutely be challenging to hold down a job while battling an illness (or several), not working can also come with its own set of difficulties, ranging from emotional to social to financial.

A lack of understanding about what it’s really like to be sick/disabled and unemployed has unfortunately led to many harmful misconceptions: Some may see the unemployment as a “vacation,” while others accuse folks who receive government assistance of trying to get a “free ride.” This is not just inaccurate, but hurtful.

The reality is that many of those who are unemployed due to health issues may struggle to make ends meet financially (the cost of appointments, medications and treatments can quickly add up), and this can lead to a great deal of stress and worry. People may also struggle with a loss of identity, purpose or sense of accomplishment – all of which a job can provide. Socially, it can be difficult to not work with or be around others each day. Staying home by yourself all day may be nice for a day or two, but it can easily become lonely or boring. Not to mention all the physical symptoms you have to cope with every day!

It can be incredibly hard to lose the ability to work. But if you find yourself in this boat, know you’re not the only one. If humor helps you cope with the challenges of not working due to chronic illness, these memes are for you. Hopefully some of these will bring a smile to your face or, at the very least, remind you that you’re not alone. 


1. When people thinking not working and staying in bed constantly is fun:


 via invisibleillnesssoldiers.blogspot.com 

2. When no job means one less reason to leave the house: via @supportforspoonies Instagram 


3. When you’re home sick but everyone you know is at work/school:


 via @Oh_heyDre Twitter 

4. When there’s nothing “relaxing” about being chronically ill: via @chronic_illness_humor Instagram


5. When chronic illness becomes your full-time job:


  via @supportforspoonies Instagram 

6. When you can sleep all day without having to call in sick to work:


 via taleas.com 

7. When not having a job makes medical bills even more daunting: via @chronicillnessmemes Instagram 


8. When you miss being able to socialize at work: 


via amyofdoom Tumblr 

9. When people think being unable to work is a vacation: via @chronicillnessmemes Instagram 


10. When you no longer need to wear work-appropriate clothing:


 via @chronicles_of_my_broken_body Instagram 

11. When people think you’re resting peacefully at home but it’s actually more like: via @spondymemes Instagram


12. When you try to create some routine in your days at home: via @banana.endo Instagram 


13. When you’re just so awesome it would be unfair of you to work full-time:


14. When no one really understands what the chronic life is like:

  via @daisy_thehedgehog_ Instagram


Paige is the Associate Chronic Illness Editor of The Mighty. She lives with an autoimmune disease and other chronic health issues, and is passionate about helping others share their health journeys and connect with one another.
Read more


Tuesday, 22 May 2018

Herbal Solutions For Nerve Pain - Don't Dismiss Them Out Of Hand

Today's post from herbalremediesadvice.org (see link below) looks at pain from the point of view of a herbalist. Now given that neuropathy is incurable and current chemical medications consistently fail to relieve the symptoms sufficiently, leading to yet more medication intake, many people look into alternative ideas. One of these ideas is using herbalism to help control pain. The problem with herbalism (despite its use for thousands of years) is that it brings out the cynic in us but before you come out with the derisory snort, it may be worth reading this article, if only to make you think about what extra you may be able to bring into your current course of treatment. Modern thinking about nerve pain and nerve damage, encourages a more holistic approach to treatment which may or may not include drugs but also tries to include a variety of treatments and therapies to give us the best chance of success. I confess that I'm also pretty cynical about herbalism but then again, I swallow daily supplements that are often herbs, minerals and the like...in a pill form, so who's fooling who here! The point is that medical practice that is thousands of years old and pre-dates modern chemical drugs, should not be dismissed out of hand, just because we have 21st century judgements about hippy thinking and new age philosophy. This article thoroughly explores the thinking behind herbalism for pain relief and offers many suggestions which may or may not appeal to you. Before you reach for the pain killers, give this a chance and maybe explore the options a bit further but as the author says; most people just want instant relief and are not prepared to put in the work, or change their ways of thinking about pain. Ask yourself how long you've been taking prescription drugs and whether they're working for you and if not, is it not worth investing a bit of time in exploring other options? Finally, remember that in herbalism as with everything else, there are con-men who'll try to lighten your wallet - do your own research and watch out for drug interactions with anything else you might take - it's a minefield out there!!



Natural Pain Relief
Rosalee de la Forȇt

Pain, the Great Motivator

The sensation of pain is a great motivator for people to seek natural pain relief. Whether you practice herbalism for your friends and family or are a clinician, pain is one of the most common complaints we hear.

Most of us were raised to take over-the-counter (OTC) medicine when we experienced pain. These pills are usually cheap, easy to acquire and take, and are often effective in the short term. The obvious problems associated with OTCs are habitual use due to recurring pain (since they never address the real problem), which gives rise to a myriad of undesirable side effects ranging from digestive problems to death.

It is common in western culture to view pain as an inconvenience. Many people I see want a safe herbal equivalent to OTCs so they can get back to their normal lives. It often takes a lot of coaching on my part to change their ideas and approaches to pain.

Sometimes this is entirely unsuccessful. I have had clients who don’t want to change how they eat or who don’t want to pay for multiple sessions in manual therapy. Instead they just want something to take the pain away. I believe people are free to make their own health choices. If they don’t want to address the underlying problem for their pain but are seeking safer alternative to over-the-counter pharmaceuticals, I help them find this solution.

Many times people have sought me out because they want a more holistic approach to their pain and are open to more drastic changes in their lives. I often work on a two-pronged approach, doing what I can to stop the pain now as well as working on the underlying issue.

Many people new to herbalism are simply looking for the safe herbal equivalent to Tylenol and they will have a difficult time finding it. This difficulty gives rise to the erroneous idea that herbs are not effective for pain. As far as I know there isn’t that one (legally available and safe) herb that will stop all pain. Instead, herbs are highly specific to the type of pain. Herbalists will be much more successful in treating pain if they can differentiate the type of pain and the cause of the pain.

This article is going to examine how we look at pain using traditional humoral and energetic markers. Having been trained as a planetary herbalist with a basic understanding of humoral western herbalism, Ayurveda and Traditional Chinese Medicine, the following draws on my own hodgepodge understanding of all these traditions. I will strive to present it in a common language for general understanding.

Before we can suggest herbs for pain we must know a lot more about the quality of the pain, the onset and severity of the pain, and the location of the pain. Please keep in mind there are a lot of different kinds of pain. Questions asked for chronic pain will differ significantly from questions regarding an acute injury. I trust the reader can draw these apart depending on the situation.

Although I will highlight some of my favorite herbs for pain, this article will be more about understanding the energetic qualities of pain, rather than a general review of the materia medica used for pain. However, I won’t stray too far into the philosophical mechanisms of pain and it is my hope that the reader will leave with practical applications for natural pain relief.

Natural Pain Relief: Determining the Quality of the Pain


For many laypeople pain is pain.

For the traditional herbalist “pain” is a general word that needs to be explored more fully. To better understand the quality of pain we can look for insights into the thermal energetics (cold vs. hot), the humidity (damp vs. dry), whether the pain is from excess or deficiency, and whether there is an influence of spasms (wind) or of stagnancy.


Thermal Energetics (Cold vs Hot) in Natural Pain Relief


Understanding whether the pain is influenced by hot or cold can be an important distinction in differentiating pain. Pain being influenced by cold or hot is not a woo-woo or ethereal concept. People with arthritis pain will tell you it’s worse in the winter when it’s cold. Or someone may know they tend to get pounding headaches in the heat of the summer. Sometimes pain induced by an imbalance of temperature can be even more obvious, like pain from a sunburn, which typically feels hot.

Here are some general questions one may ask to determine the "temperature" of the pain.

Do you prefer cold/warm temperatures? Is your pain increased with coldness/warmth? Is pain ameliorated with cold/warmth? Do you notice more discomfort in the winter/summer? Palpating the specific area of pain, does it feel cold? Does it feel warm? If pain is systemic, do you tend to feel cold or warm?

Of course answers are seldom black and white. The person may feel cold in their extremities while the area of pain is hot, or vice versa. In general we want to address acute situations before more chronic or constitutional considerations.



  

Natural Pain Relief Associated with Coldness

The person who has systemic pain associated with coldness generally has a pale complexion and may be cool to the touch. They may have a dislike or even fear of the cold. I often hear from these people that they have trouble sleeping at night because they are so cold. They typically are wearing more clothes than anyone else in the room. Their tongue may be pale in color. If they have a coating on the tongue it will tend to be white. Their pulse may be slow. Pain associated with coldness tends to be chronic like arthritis or pain from fibromyalgia. The pain may be be dull or achy and constant.

Plan of action:

Generally these people can benefit from warming herbs for pain. Warm teas, cooked whole foods with lots of spices and warm baths may all be helpful. Circulatory stimulants are commonly used for this type of pain and include ginger (Zingiber officinale), turmeric (Curcuma longa), cayenne (Capsicum spp.), bee balm (Monarda spp.).

Natural Pain Relief Associated with Heat


Signs of constitutional or systemic heat may include a completely red face, loud voice, fast pulse, red tongue with possible yellow coating. They may thrive in cooler temperatures and complain of wilting in higher temperatures. Other heat signs in the body may include ulcers on the lips, mouth, stomach or intestines.

Pain associated with heat might be radiating, throbbing, hot to the touch, and intense. Acute injuries often have some element of heat to them. Sprains or burns will often be warm to the touch.

Plan of action:

For systemic pain, bitter and heat-clearing herbs for pain may be of benefit here. Herbs containing salicylic acid such as willow (Salix spp.) and meadowsweet (Fillipendula ulmaria) fall into this category nicely. Nerve pain often falls into this category and herbs like St. John’s Wort (Hypericum perfoliatum) and Cow Parsnip (Heracleum spp.) can be of great benefit.

Pain associated with heat often has some element of inflammation present. We have amazing anti-inflammatory herbs for pain such as turmeric (Curcuma longa), rosemary (Rosmarinus officinalis), St John’s Wort (Hypericum perfoliatum), licorice (Glycyrrhiza glabra), and on and on and on. Usually diet and lifestyle will need to be reviewed as well.

Acute injuries (sprains, strains, bruises) benefit from the topical application of herbs for pain such as liniments, poultices, fomentations etc. Hydrotherapy, which has a long history of traditional use, and herbal baths/soaks can be of great benefit as well. Blood-moving herbs for pain can both relieve pain and reduce swelling. I often reach for a blend of arnica-infused oil and arnica liniment for acute pain in closed skin traumas.

For visibly hot traumas like burns, cooling herbs for pain work exceptionally well. Even someone who couldn’t identify a dandelion correctly can tell you that aloe relieves the pain of burns. I also use aloe for herpes sores as it can stop a blister from forming, can relieve the pain and help to heal the blister.

Ice is often recommended in western science for acute injury. Ice is topically anesthetic and will temporarily numb pain. It constricts the tissue, slows circulation to the site of the injury and may lessen swelling.

Traditional Chinese Medicine historically does not recommend ice. I also do not recommend ice even in acute injury. Ice congeals the blood and creates stagnation. A recent study demonstrated that icing an injury stopped the growth hormone, which is essential to healing.

Discussing the topic of icing an injury among modern day herbalists raises a lot of controversy from all sides of the issue. The best we can do is research the issue from different perspectives and then rely on our own experience from personal application.



 


  

Humidity (Damp vs Dry) in Natural Pain Relief


Natural Pain Relief Associated with Dampness

Pain associated with dampness is pain increased with humidity (humid environments, rain) and a feeling of heaviness, especially in the lower limbs. Dampness can often be a component of arthritis pain. The area affected may feel damp and appear swollen. Pushing on the tissues may leave an indentation for an extended period of time.

Plan of action:

Dampness usually presents with a hot or cold component that also needs to be addressed for the individual (see above). Dampness can accumulate through environmental factors, such as living in a damp environment, or as a result of cold digestion. Herbs for pain that drain dampness (diuretics) or transform dampness, as well as dietary intake can also be an important part of controlling dampness.

Dampness may be involving the lymphatic system and in these cases herbs that move the lymph are helpful. Sweating therapies can also be of great benefit.

Natural Pain Relief Associated with Dryness

Dryness can also manifest with arthritis pain or joint pain. Joints may crack and have a sensation of friction. The person will also most likely have other signs of dryness such as dry hair, dry skin or dry mucosal membranes.

Plan of action:

Demulcent herbs or yin tonics and an increased intake of healthy fats and essential fatty acids are indicated.

Excess vs Deficiency in Natural Pain Relief

Natural Pain Relief Associated with Excess

Chronic excessive pain will most likely be paired with someone who tends toward an excessive constitution. The pain may be increased after eating and be aggravated by pressure or touch. Eliminating herbs such as those found under the alterative classification can be helpful in treating constitutionally.

Acute injuries such as sprains will fall under this category as well.

Natural Pain Relief Associated with Deficiency


Pain associated with deficiency may be dull, chronic, relieved by pressure, better after eating and accompanied with fatigue. These people can use building and tonifying therapies such as adaptogen herbs, wholesome foods, blood builders etc.

Movement (Wind) vs Stagnation in Natural Pain Relief

Natural Pain Relief Associated with Wind

Pain associated with wind is pain caused by spasming or constricted tissues. Pain that moves around may be due to wind.

Plan of action:

Herbs for pain excel at relieving pain associated with constriction and spasming whether it is muscle spasms in the back or neck, menstrual cramping, or even pain associated with the passing of kidney stones. From a modern perspective we know that many people are deficient in magnesium and symptoms of this include muscle spasms.

Applying heat and herbs for pain topically and taking antispasmodic herbs internally can work wonders on relieving pain. When indicated, magnesium supplements can help relieve pain and the underlying cause of the pain. Antispasmodic herbs I use frequently include valerian (Valeriana officinalis), lobelia (Lobelia inflata) and cramp bark (Viburnum opulus.)

Natural Pain Relief Associated with Stagnation

Stagnant pain is usually fixed and throbbing. The person can point with their finger to the exact location that is a problem. The area may feel hot or cold.

Plan of action:

Move the stagnancy with a category of herbs called blood movers in Traditional Chinese Medicine and that often fall under the category of emmenagogues in western herbalism. Stagnancy is usually accompanied by a deficiency or an excess as well as a thermal imbalance and all need to be addressed.

Natural Pain Relief: Determining the Onset of the Pain

Knowing the onset of pain can help determine the underlying cause. It can also help the practitioner understand the severity of the situation.

One of the most powerful gifts we can give our clients is the gift of awareness. Helping a person to be conscious of their body, knowing how the pain starts to manifest, what triggers it and what makes it better can go a long way in empowering them to get out of pain.

Red flags for pain include sudden pain down the left arm accompanied with nausea (possible heart involvement), sudden vomiting followed by pain (possible appendix troubles), severe lower back pain that is constant and accompanied by a fever (possible kidney infection), sudden pain accompanied by any other persistent symptoms such as vomiting, extreme fever, constant diarrhea, bladder dysfunction etc. All of these should be handled by someone with the appropriate experience, most likely a medical physician.


  


Natural Pain Relief: Determining the Severity of the Pain

The subjective experience of pain is often measured on a 1-10 pain scale. Here’s how I like to break this down.

1 - 3 pain scale: Pain is noticeable but the person is able to ignore it for the most part and perform regular functions of daily life. Not normally a big concern for them.

4 - 7 pain scale: Pain encroaches on their ability to perform daily life activities. Oftentimes they need some sort of pain management in order to function or else they must limit offending activities.

8 - 10 pain scale: Life is becoming intolerable. Pain inhibits their normal daily life activities. Bed rest or large doses of pain medications are necessary.

This pain scale can fluctuate tremendously and apply to constant pain or intermittent pain. Pain may be worse in the morning, worse at night, worse with a specific activity, worse at a particular time of the month in a particular season and so on.

Getting a subjective record of pain is important not only for understanding the current situation but also for recording improvement or deterioration. It’s very common for people to report “no change” in their pain, although they show significant improvement when asked to quantify their pain on a scale. Being able to demonstrate this to a client will help them to be optimistic about their path to wellness and keep them on track.

Natural Pain Relief: Determining the Location of the Pain


The location of pain can give us an obvious understanding of whether we are dealing with a headache or an ulcer. Very helpful!

In Traditional Chinese Medicine the location of pain can help point to the underlying problem. Studying acupuncture meridians can be a helpful field of study. Some herbs for pain are specific for particular areas of pain and specific types of pain. Studying simples and herbalism through the eyes of an eclectic physician can also be a useful guide to relieving pain.

Be Mindful of Oversimplification


The energetic considerations above are presented in a "black and white" format for an introductory understanding. People seldom present with one manifestation and are more commonly seen with a multitude of influences. An herbal formula created specifically for a particular person is often the most powerful means to stopping pain.

Instead of a dogmatic truth to follow, I offer the above guidelines as a general understanding to a particular person’s pain. These basic guidelines may provide additional assistance when a pain protocol is not working.

For example, if someone consistently relied on willow bark as a general pain reliever but found that it wasn’t working in a particular instance, a further look into to the energetics of the situation as well as the person will hopefully guide them towards greater success.

I want to acknowledge that there are also low-dose botanicals that can be used to relieve severe pain. The application of these potentially toxic plants are beyond the scope of this article.

The Underlying Cause


When someone’s major complaint is pain I am ideally applying a two-pronged approach. Of course I want to relieve their pain soon, but I also want to address the underlying cause of the pain. The reasons for pain are as varied as the people you’ll see so I will cover only a few reasons that I see regularly.

Sometimes by addressing the pain energetically we can also address the underlying cause. For example, if a person is experiencing pain because they have excessive coldness then applying warming and nourishing/building therapies may relieve their pain as well as the cause of their pain.

Insulin resistance is rampant in this society and is an inflammatory disease by nature. It can be a factor in a number of pain problems such as gout, kidney stones and even arthritis.

Food intolerances can also lead to a variety of painful conditions, including arthritis, debilitating bowel problems and headaches.

Structural imbalances can play a large role in pain symptoms. Referring people to trusted specialists in this area can be very useful. This may include structural integration, yoga, pilates, network spinal analysis, feldenkrais etc.

Stress and emotional challenges can play a huge role in pain and should never be overlooked.

Conclusion for Natural Pain Relief


Acute or chronic pain can be a vulnerable experience. The more we know about the pain the better we can help to both relieve a person’s current symptoms and prevent the pain from reoccurring.

This article was originally published in the Plant Healer Magazine.

https://www.herbalremediesadvice.org/natural-pain-relief.html

Monday, 21 May 2018

The Nightmare Scenario For Genuine Chronic Pain Patients Has Arrived (Vid)

Today's post from kstp.com (see link below) may pretty well be the shape of things to come for chronic neuropathy sufferers who depend on opioids to control their pain and it's a horrifying prospect. You may well say that this is a localised set of guidelines in the USA but whatever happens in the States, tends to make its way across the world in due course. You can debate the arguments all you like but this set of guidelines is so strict that it verges on inhumane treatment of genuine patients. When the authorities see a drug as simply narcotics that are by definition evil, then you know that media hysteria has taken over from reason. The problem is that politicians jump on bandwagons as soon as they see a potential vote winner on the horizon and the nuances are simply ignored. There has to be accommodation for genuine patients with chronic pain conditions who depend on their medications to be able to live reasonably productive and normal lives. Take away the pain killers and you will see suffering on a hitherto unknown scale, all under the guise of protecting people from themselves. If you have severe neuropathy and are on opioid-family medications, you're going to need to fight for your rights to live relatively pain free. The onus is on the doctors to monitor and control their patients so that they don't become addicted and can switch/mix and match drugs when necessary, precisely to avoid that. That requires doctors to literally be on the case and not simply re-issue prescriptions ad infinitum. Genuine patients will do anything to avoid becoming addicted and don't ever want to be on opioids but they have no choice - everything else has failed and they need a carefully monitored medication program that combines holistic treatments and therapies...plus the drugs. That does not mean that the drugs should be taken away from the one week to the next. Draconian laws have never solved medication problems and they won't now. If ever we needed good advocacy, it's now!

Opioid Prescription Guidelines Now in Effect

 May 18, 2018 06:58 PM




3.5 million opioid prescriptions were written in Minnesota in 2016, and at least half of those pills ended up in the wrong hands, according to the Department of Human Services.

RELATED: Lawmakers Debate Opioid Taxes as States Grapple with Crisis


It's one reason new state guidelines were established to limit pills the number of being prescribed.

"These guidelines are really, really strict. They're the strictest I've ever seen," Dr. Mark Willenbring with Alltyr Clinic said.

He founded the St. Paul-based individualized treatment and therapy clinic about five years ago and has been studying addiction for nearly 40 years.

"I think we needed to cut back but I think we've cut back too far," he said of the state's new prescription guidelines that went into effect at the end of April.

In short, the guidelines outline three recommendations for providers:

1.) After an injury or surgery, avoid prescribing more than a three-day supply, or 20 pills.

2.) After that, prescribe opioids only for a seven-day time period and reassess.

3.) For chronic pain, avoid starting opioid therapy whenever possible and carefully manage any patient who remains on medication.

"I've got several patients right now that I'm maintaining on opioids for chronic pain and they're doing very well," Willenbring said. "Now, you take them off of that and they will not do well at all. They will go from 16 hours up and active a day to two hours up and active a day."

"These are narcotics," Acting Commissioner for the Department of Human Services Chuck Johnson said. "They change your brain chemistry so you use them enough over time, and you need to have more and more."

Johnson says the most dangerous period of time is within the first 45 days of use, and that addiction can happen within the first five days.

Minnesota Opioid Action Plan

"This isn't something that we're forcing on anyone," he said. "I think the whole healthcare industry and healthcare professionals are recognizing that there's a problem we need to address."

The state will monitor prescribers and flag those who stray from the guidelines, first working to help them adjust to the changes but will eventually impose repercussions if needed.

"If we have individuals who continue to overprescribe and not follow the guidelines, they could be removed as providers from our programs," Johnson said. That includes Medicaid and MinnesotaCare.

RELATED: Dayton Proposes Tax on Drug Companies in Effort to Combat Opioid Epidemic

"We cover about 20 percent of the state through our programs," he said.

"It's not going to do anything for the opioid problem in the state because the problem has shifted," Willenbring said. He believes the real problem lies with street drugs like heroin.

"It's mainly going to deprive people who need pain medication from getting it," he said.

The state can only oversee so much and is also working with individual health care providers to help monitor prescribers.

There are some exceptions to the guidelines. Examples include those who are addicted and depend on medically-assisted therapy, those in cancer treatment, and those in hospice care.

You can read more about the guidelines by clicking here.

Credits


Katherine Johnson


Updated: May 18, 2018 06:58 PM

Created: May 18, 2018 05:31 PM

http://kstp.com/medical/opioid-prescription-guidelines-now-in-effect/4913845/

Sunday, 20 May 2018

Childhood Cancer Treatment And Resulting Lifelong Neuropathy

Today's post from jamanetwork.com (see link below) makes for especially painful reading because you quickly realise that it actually concerns the future of neuropathy treatment and the sort of patients who may have to live with the symptoms for the rest of their lives. For children, the rest of their lives, is a very long time indeed! As adults, we know how difficult living with neuropathy is to manage - how difficult must it be for a child with both cancer and nerve damage! It makes you wonder if the sorts of chemotherapy that normally cause nerve damage, can't be substituted with less damaging forms but they've surely thought of that haven't they? The fact remains that childhood cancer is tragic enough without piling lifelong neuropathy symptoms on top - how cruel can life be!! Unfortunately, the fact also remains that without the chemotherapy treatment that can remove the cancer, the patient may die - so once again, they're left between a rock and a particularly hard place. Oh for that magic wand when you need it! It's a complex, heavyweight article but is worth the effort, if only to encourage us to push even harder for effective neuropathy research resulting in effective treatments.


Chemotherapy-Induced Peripheral Neuropathy in Long-term Survivors of Childhood Cancer - Clinical, Neurophysiological, Functional, and Patient-Reported Outcomes
May 14, 2018
Tejaswi Kandula, MBBS1,2; Michelle Anne Farrar, MBBS, PhD1,2; Richard J. Cohn, MBBCh3; et al David Mizrahi, MSc3,4; Kate Carey, PhD1; Karen Johnston, RNMN3; Matthew C. Kiernan, MBBS, PhD5; Arun V. Krishnan, MBBS, PhD6; Susanna B. Park, PhD5,6
Author Affiliations Article Information
JAMA Neurol. Published online May 14, 2018. doi:10.1001/jamaneurol.2018.0963


Key Points

Question What is the disease burden and functional effect of chemotherapy-induced peripheral neuropathy in childhood cancer survivors?

Findings In this cross-sectional study including 121 childhood cancer survivors, long-term deficits in clinical, electrophysiological, and functional measures of peripheral neuropathy were common, and concurrent deficits in patient-reported outcome measures suggest a significant effect. Cisplatin has a greater neurotoxicity profile than vinca alkaloids.

Meaning Both the type of neurotoxic agent used and a targeted clinical neurological assessment are important considerations when screening childhood cancer survivors for long-term neuropathy.

Abstract


Importance In light of the excellent long-term survival of childhood cancer patients, it is imperative to screen for factors affecting health, function, and quality of life in long-term survivors.

Objective To comprehensively assess chemotherapy-induced peripheral neuropathy in childhood cancer survivors to define disease burden and functional effect and to inform screening recommendations.

Design, Setting, and Participants In this cross-sectional observational study, cancer survivors who were treated with chemotherapy for extracranial malignancy before age 17 years were recruited consecutively between April 2015 and December 2016 from a single tertiary hospital-based comprehensive cancer survivorship clinic and compared with healthy age-matched controls. Investigators were blinded to the type of chemotherapy. A total of 169 patients met inclusion criteria, of whom 48 (28.4%) were unable to be contacted or declined participation.

Exposures Chemotherapy agents known to be toxic to peripheral nerves.

Main Outcomes and Measures The clinical peripheral neurological assessment using the Total Neuropathy Score was compared between recipients of different neurotoxic chemotherapy agents and control participants and was correlated with neurophysiological, functional, and patient-reported outcome measures.

Results Of the 121 childhood cancer survivors included in this study, 65 (53.7%) were male, and the cohort underwent neurotoxicity assessments at a median (range) age of 16 (7-47) years, a median (range) 8.5 (1.5-29) years after treatment completion. Vinca alkaloids and platinum compounds were the main neurotoxic agents. Clinical abnormalities consistent with peripheral neuropathy were common, seen in 54 of 107 participants (50.5%) treated with neurotoxic chemotherapy (mean Total Neuropathy Score increase, 2.1; 95% CI, 1.4-2.9; P < .001), and were associated with lower limb predominant sensory axonal neuropathy (mean amplitude reduction, 5.8 μV; 95% CI, 2.8-8.8; P < .001). Functional deficits were seen in manual dexterity, distal sensation, and balance. Patient-reported outcomes demonstrating reduction in global quality of life and physical functioning were associated with the Total Neuropathy Score. Cisplatin produced long-term neurotoxicity more frequently than vinca alkaloids.

Conclusions and Relevance Clinical abnormalities attributable to peripheral neuropathy were common in childhood cancer survivors and persisted long term, with concurrent deficits in patient-reported outcomes. Both the type of neurotoxic agent and a targeted clinical neurological assessment are important considerations when screening survivors for long-term neuropathy. Further development of peripheral neuropathy–specific pediatric assessment tools will aid research into neuroprotective and rehabilitative strategies.

Introduction

The changing landscape of childhood cancer treatment over the last 6 decades has seen the improvement of childhood and adolescent cancer survival rates to 80% or greater for many cancer types.1,2 A child who survives 5 or more years after cancer diagnosis has a life span comparable with other persons of their age.3 In view of this excellent long-term survival, it is important to characterize the long-term morbidity from cancer treatment in the context of a significant burden of long-term health conditions in childhood cancer survivors (CCS).4-6

Chemotherapy-induced peripheral neuropathy (CIPN) is a potentially long-lasting adverse effect of commonly used chemotherapy agents in pediatric practice, principally vincristine and other vinca alkaloids, cisplatin, and carboplatin.7 To our knowledge, long-term outcomes of peripheral neuropathy from these agents in children remain to be fully delineated. Neuromuscular impairment and restricted participation in daily activities are observed in CCS,8-10 and persistent deficits in fundamental motor skills are demonstrable in children following completion of cancer treatment.11 Multiple factors, such as obesity, poor bone health, and psychosocial health, may be part of a complex interaction that limits physical activity, which in turn perpetuates and maintains long-term health conditions.4,5,12,13 Chemotherapy-induced peripheral neuropathy may be a key factor contributing to reduced physical performance, and defining its effect is an important consideration in the design of any interventional programs. While other studies have demonstrated physical limitations in CCS,8,9,14,15 this study aims to extend these findings by providing a comprehensive multimodality evaluation of CIPN in long-term survivors of extracranial childhood cancer across multiple cancer types to define the disease burden and its functional effect as well as to inform recommendations for screening in this population.

Methods

Childhood cancer survivors treated with chemotherapy for extracranial malignancy before the age of 17 years at the Kids Cancer Centre, Sydney Children’s Hospital, Sydney, Australia, were recruited consecutively between April 2015 and December 2016 from the long-term follow-up clinic. Patients with other causes of peripheral neuropathy, such as diabetes, history of critical illness neuropathy, known inherited neuropathic conditions, or other neurodevelopmental disorders, were excluded. The study was approved by the Sydney Children’s Hospitals Network Human Research Ethics Committee. Written informed consent was obtained from each participant or their parent/guardian in accordance with the Declaration of Helsinki.

A comprehensive neurotoxicity assessment was carried out with each participant. For participants younger than 17 years, this included the pediatric-modified Total Neuropathy Score (TNS) for clinical measures, the Movement Assessment Battery for Children (MABC) for functional measures, nerve conduction studies for neurophysiological measures, and the Pediatric Quality of Life Inventory Generic Core Scales (PedsQL) and the Pediatric Outcomes Data Collection Instrument (PODCI) for patient-reported outcome (PRO) measures. For participants 17 years or older, this included the TNS clinical version for clinical measures, Von Frey monofilaments, grating orientation task, and grooved peg board task for functional measures, nerve conduction studies for neurophysiological measures, and the European Organisation for Research and Treatment of Cancer (EORTC) quality-of-life questionnaire and chemotherapy-induced peripheral neuropathy questionnaire (CIPN20) for PRO measures (eMethods and eTable 1 in the Supplement). Investigators were blinded to the type of chemotherapy.

Statistical analyses were conducted in consultation with a biostatistician using SPSS Statistics version 23 (IBM) and Prism version 7 (GraphPad). Comparisons used 2-tailed t tests and Mann-Whitney U tests for nonparametric subgroup analyses, χ2 tests for nominal data, 1-way analysis of variance for multiple groups, and Pearson or Spearman (small or ordinal data sets) correlations. Results are stated as means with standard deviations, and a P value less than .05 was considered significant. Bonferroni-corrected P values were used for correlations with multiple PROs.

Results were compared with healthy age-matched controls (age range, 6-56 years) or established population reference ranges for pediatric functional and PRO measures (eMethods and eTable 2 in the Supplement). In addition to group-level comparisons, individual item variance for each participant’s performance was calculated using the following formula: (control mean time − participant time) / control standard deviation. The 1-sample t test was used to compare the group variances with 0. The participant group mean was compared with the population mean and expressed as mean standard deviations above or below the population mean. Hierarchical linear regression models of neurophysiological and PRO measures with stepwise inclusion of predictive variables that may assist in screening CCS, including demographic, malignancy, and treatment variables, as well as concurrent clinical, neurophysiological, and functional outcomes were constructed to determine effect size (R2 increase) of each variable.

Results

A total of 169 patients met the inclusion criteria, of whom 48 (28.4%) were unable to be contacted or declined participation because of competing appointments or not wanting to participate in research. Neurotoxicity assessments were conducted in 121 CCS, of whom 65 (53.7%) were male, at a median (range) age of 16 (7.0-47.0) years, including 107 (88.4%) who received neurotoxic chemotherapy agents and 14 (11.6%) who received a protocol with no neurotoxic agents. Exposure to chemotherapy occurred a median (range) age of 4 (0-17.5) years, and the participants were tested a median (range) 8.5 (1.5-29.0) years after completion of their treatment (Table 1). Demographic characteristics are described for the entire cohort of 121 participants, but comparisons for all CIPN parameters were carried out between individual subgroups (ie, CCS who received neurotoxic chemotherapy vs controls or CCS who did not receive neurotoxic chemotherapy vs controls).

Radiotherapy exposure was seen in 50 of 107 CCS (46.7%) who received neurotoxic chemotherapy; 12 (11.2%) had cranial or craniospinal irradiation, 25 (23.4%) had extracranial involved-field irradiation, 12 (11.2%) had total body irradiation, and 1 (0.9%) had both cranial and total body irradiation. Additionally, 21 CCS (19.6%) who received neurotoxic chemotherapy also received a bone marrow transplant. Twenty CCS (18.7%) had a body mass index (calculated as weight in kilograms divided by height in meters squared) in the overweight category (>25), and 4 (3.7%) were in the obese category (>30).

Vinca alkaloids were the most commonly used neurotoxic chemotherapy agent and were used in 86 of 121 CCS (71.1%), of whom 81 (66.9%) received vincristine as the sole neurotoxic agent and 5 (4.1%) received multiple vinca alkaloids. Platinum agents were prescribed to 20 CCS (16.5%), including 7 (5.8%) who received cisplatin, 7 (5.8%) who received carboplatin, and 6 (5.0%) who received cisplatin and carboplatin; 7 (5.8%) were prescribed platinum agents as the only neurotoxic therapy and 13 (10.7%) were prescribed platinum agents in combination with vinca alkaloids. Thalidomide was the sole neurotoxic agent in 1 participant (0.8%). Numbers of patients, age, and sex distributions for the CCS and controls in the adult and pediatric age groups for each of the CIPN parameters are presented in eTable 2 in the Supplement.

Clinical Findings

Participants treated with neurotoxic chemotherapy demonstrated a significant increase in signs and symptoms of neuropathy as assessed via the TNS (mean [SD; range] score: CCS, 2.9 [3.2; 0-14]; controls, 0.8 [1.0; 0-4]; P < .001) (Table 2). Total Neuropathy Score abnormalities were present in 53 of 100 CCS (53.0%) treated with neurotoxic chemotherapy and 5 of 36 controls (14%). More prominent abnormalities of the peripheral clinical neurological assessment (TNS > 3) were more prevalent in CCS treated with a cisplatin-containing protocol (10 of 12 [83%]) compared with CCS treated with vinca alkaloids (23 of 80 [29%]), CCS treated with carboplatin without cisplatin (2 of 7 [29%]), CCS who did not receive any neurotoxic agents (2 of 13 [15%]), or controls (1 of 36 [3%]) (P = .001).

Neurophysiological Findings

The lower limb sural sensory amplitudes were smaller in CCS exposed to neurotoxic chemotherapy compared with age-matched controls (mean reduction, 5.8 μV; 95% CI, 2.8 to 8.8; P < .001) suggesting a reduced number of functioning axons (Table 2). In comparison, no significant reduction was seen in the sural amplitude in CCS not exposed to neurotoxic chemotherapy (mean reduction, 0.4 μV; 95% CI, −6.7 to 5.9; P = .90).

A sural amplitude below the mean (SD) control recording of 23.3 (7.8) μV was observed in 65 of 85 CCS (76%) treated with neurotoxic agents (Figure 1). Compared with population reference values, a sural amplitude below the age-appropriate reference ranges was noted in 20 CCS (24%) treated with neurotoxic chemotherapy (12 of 66 [18%] with vinca alkaloids and 7 of 18 [39%] with platinum agents).16-18 A total of 14 of 85 (16%) had an abnormal sural amplitude as well as an abnormal TNS, fulfilling criteria for peripheral neuropathy.19 No significant difference was observed in the sural sensory conduction velocity (0.9 m/s; 95% CI, −1.3 to 3.1; P = .40).

In contrast, there were no significant differences in motor amplitudes between CCS treated with neurotoxic agents and controls, including amplitudes from the tibial nerve to abductor hallucis (−0.4 mV; 95% CI, −2.0 to 1.2; P = .60) and the peroneal nerve to extensor digitorum brevis (−1.0 mV; 95% CI, −2.1 to 0.2; P = .09). Comparable values were also obtained for the upper limb median (SD) sensory amplitudes for CCS (60.2 [28.0] μV) and controls (61.6 [21.9] μV) (P = .80). Individually, compared with population reference ranges, abnormal values were seen in 1 of 85 CCS (1%) for tibial motor amplitude, 3 of 44 (7%) for peroneal motor amplitude, and 4 of 103 (3.9%) for median sensory amplitude. All but 1 CCS with abnormalities in other nerves also had an abnormal sural amplitude.

Functional Assessment Findings

In child and adolescent participants, there was no significant difference between CCS treated with neurotoxic agents and population references in the mean (SD) combined score percentiles of manual dexterity (43.2 [28.6]), aiming and catching (56.4 [30.1]), or balance (46.2 [31.8]) using the MABC. However, 2 of 3 individual manual dexterity tasks and 1 of 3 balance tasks demonstrated impairment in CCS (Table 2; Figure 2).

In adult participants, impaired performance was seen in the neurotoxic group compared with controls in distal sensory and motor tasks using Von Frey monofilaments testing light touch sensation (increased threshold, 0.1 mN; 95% CI, 0.03 to 0.2; P = .01), the grating orientation task testing cutaneous spatial resolution (increased threshold, 0.7 mm; 95% CI, 0.1 to 1.2; P = .003), and the grooved peg board testing manual dexterity (increased time to completion, 5.9 seconds; 95% CI, 1.6 to 10.1; P = .008) (Table 2; Figure 2). This translates to a difference of 0.4, 0.5, and 0.6 SDs, respectively, compared with controls. Additional matching for sex for the grooved peg board, given known sex differences in performance (eMethods in the Supplement) demonstrated a similar difference in the mean, which did not reach statistical significance in the context of a smaller sample size (increased time to completion, 4.7 seconds; 95% CI, 0.1 to 9.5; P = .06).

Comparison of CCS who did not receive any neurotoxic chemotherapy with controls did not demonstrate any functional differences except in the grating orientation task in the adult group (increased threshold, 0.5 mm; 95% CI, 0.003 to 1.0; P = .049). However, there were only small sample sizes in these subgroups (8 child and adolescent participants and 6 adult participants).

Patient-Reported Outcomes

Parent proxy reports for child and adolescent participants in the neurotoxic group demonstrated significant impairment and participation restriction across multiple domains, including the PedsQL physical domain (−0.4 SD; 95% CI, −0.6 to −0.1; P = .01) and psychosocial domain (−0.8 SD; 95% CI, −1.1 to −0.5; P < .001) and the PODCI sports and physical functioning domain (−0.4 SD; 95% CI, −0.8 to −0.1; P = .008). In comparison, child/adolescent self-report demonstrated impairment in the PedsQL psychosocial domain only (−0.3 SD; 95% CI, −0.5 to −0.05; P = .02) (eTable 3 in the Supplement).

In adult participants in the neurotoxic group, greater symptom report and poorer functioning and quality of life (QOL) were evident in all domains of the EORTC quality-of-life questionnaire (reduced physical functioning, 5.0 points; 95% CI, 0.9 to 9.1; P < .001) and CIPN20 questionnaire, except the autonomic symptom scale (increased neuropathy symptoms, 4.7 points; 95% CI, 1.2 to 8.2; P < .001) (eTable 3 in the Supplement). The 14 participants not exposed to chemotherapy (8 child and adolescent participants and 6 adult participants) were not different from controls in any of the domains.

Correlations

The clinical findings (TNS) were associated with the neurophysiological findings as well as the PRO measures for child and adolescent CCS (lower limb sural amplitude: Pearson correlation coefficient [r] = −0.33; P = .002; parent-reported PedsQL physical domain: Spearman correlation coefficient [rs] = −0.44; P < .001; parent-reported PedsQL psychosocial domain: rs = −0.43; P < .001; parent-reported PedsQL overall function domain: rs = −0.45; P < .001; parent-reported PODCI sport and physical function domain: rs = −0.31; P = .02; self-reported PedsQL physical domain: rs = −0.29; P = .03; self-reported PedsQL psychosocial domain: rs = −0.33; P = .01; self-reported PedsQL overall function domain: rs = −0.34; P = .01; and self-reported PODCI sport and physical function domain: rs = −0.38; P = .008). Notably, there was also a positive correlation between the parent-reported and self-reported overall function PedsQL (r = 0.66; P < .001) and PODCI sport and physical function (r = 0.66; P < .001) domains.

Adult and pediatric functional outcomes did not correlate with TNS, neurophysiological, or PRO measures. Importantly, no correlation was seen between vincristine dose and TNS or neurophysiological measures.

Risk Factors and Predictors


The TNS was the most significant predictive variable for PRO as well as neurophysiological outcomes, making it a valuable screening tool for CIPN-related deficits (Table 3). Following univariate analysis, radiotherapy (any location), sural amplitude, and TNS were the most probable significant predictors of PROs. Multivariate hierarchical linear regression demonstrated that the TNS was able to predict 25.6% of variability in parent-reported PedsQL scores (R2 = 0.38; β coefficient = −0.54; P < .001) and 22.6% in self-reported PedsQL scores (R2 = 0.24; β coefficient = −0.52; P = .001), 28.6% in parent-reported PODCI sport and physical function domain (R2 = 0.40; β coefficient = −0.57; P < .001), and 46.5% in the EORTC CIPN20 questionnaire (R2 = 0.47; β coefficient = 0.77; P < .001). The TNS was also the only significant predictor of neurophysiological (sural amplitude) outcomes, predicting 10% of the variability (R2 = 0.09; β coefficient = −0.32; P = .004) (Table 3). Importantly, age at diagnosis, time since completion of treatment, body mass index, type of malignancy, type of chemotherapy, and bone marrow transplantation were not predictive of neurophysiological or patient-reported deficits.

Discussion

Comprehensive, multimodal assessment of long-term survivors of extracranial childhood malignancy identified coherent abnormalities attributable to CIPN across objective and subjective measures. This study included participants who received multiple forms of treatment for a wide range of cancer types, increasing the generalizability of the findings. Clinical abnormalities are common and evident early in CCS and are accompanied by an overall reduction in the number of axons, manifesting as a length-dependent, predominantly sensory axonal neuropathy. Abnormalities are more prevalent following exposure to cisplatin, suggesting a greater neurotoxicity profile. Clinical abnormalities were correlated with deficits in PROs and QOL, suggesting that these changes are clinically relevant and important to monitor in CCS. There may be multiple risk factors that predispose CCS to the development of CIPN, including the type of neurotoxic agent and a genetic predisposition, and further delineation of these risk factors is critical to neuroprotective strategies.7,20 Recent evidence of benefit from targeted exercise intervention in pediatric inherited neuropathy provides the rationale for further similar therapeutic research in patients with CIPN.21

The widespread reduction in sural amplitude following exposure to neurotoxic chemotherapy, with 23.5% of CCS below population reference ranges, suggests an irreversible reduction in the number of functioning axons. This reduction is not evident in the CCS subgroup not exposed to neurotoxic chemotherapy. In contrast to the predominantly motor acute vincristine neuropathy reported in children,22,23 our study identified a predominantly sensory long-term neuropathy with both vinca alkaloids and platinum agents, similar to findings in adults.24 This may be due to lack of protection from the blood-nerve barrier in the sensory dorsal root ganglia25 as well as an underappreciation of acute sensory manifestations during chemotherapy treatment in the pediatric population. Additionally, long-term negative sensory symptoms, such as numbness, may not be recognized if present from an early age. Electrophysiological assessments by Jain et al26 within 3 years and by Ramchandren et al15 within 7 years after completion of treatment report a predominantly motor neuropathy. Both studies lacked a control group and used exceptionally broad reference ranges for the sural amplitude,27 which may have precluded the recognition of a sensory neuropathy. A larger study by Tay et al28 reported a mixed motor and sensory neuropathy 4 years after completion of vincristine treatment in 68.3% of patients. The predominantly sensory neuropathy that we observed in a smaller proportion of vincristine-treated participants at a longer median follow-up of 8.5 years suggests that neural recovery from acute vincristine injury occurs over several years and that motor nerves may recover better than sensory nerves. The concurrent presence of sensory neuropathy in all but 1 patient with abnormal motor studies in our cohort reinforces the long-term susceptibility of sensory nerves, with additional motor nerve involvement in some cases.

A key finding in this study is the greater long-term neurotoxicity of cisplatin compared with vinca alkaloids, previously underrecognized in the pediatric population.7 Young adults systematically assessed 13 years after treatment with cisplatin demonstrate long-term clinical sensory neuropathy in up to 72%,29-31 with little or no electrophysiological recovery.32,33 In comparison, 30% to 40% of adults treated with vincristine had symptoms or signs of neuropathy up to 3 years after completion of treatment, with continued long-term improvement and at least partial electrophysiological recovery.34,35 These differences in neurotoxicity profiles may be caused by differential underlying mechanisms. Platinum agents have been shown to be toxic to the cell bodies in the dorsal root ganglia, causing anterograde neuronal loss rather than the retrograde axonopathy described with vinca alkaloids, which may be more amenable to recovery.36,37 While carboplatin is generally considered less neurotoxic than cisplatin,38 some of the CCS receiving carboplatin had comparable neurotoxicity with those receiving cisplatin. However, its neurotoxicity in isolation is difficult to ascertain because of the small number of patients in this cohort receiving carboplatin alone.

The reduction in the number of residual axons in this cohort suggests a smaller axonal reserve following exposure to neurotoxic chemotherapy. The natural history of aging involves a reduction in axonal responses over the life span,17,39 which, in the context of a reduced axonal reserve, may confer a greater susceptibility to reduced function at an earlier age. Childhood cancer survivors are also at an increased risk of metabolic syndrome and diabetes.13,40,41 Diabetes is one of the leading causes of peripheral neuropathy worldwide, and it is being increasingly recognized that impaired glucose tolerance, prediabetes, metabolic syndrome, and obesity can also manifest peripheral neuropathy.42-44 Consequently, CCS may be at a greater risk of diabetic and prediabetic neuropathy, and this underscores the need for vigilance in this population as well as the importance of screening for early signs of peripheral neuropathy. Chemotherapy-induced peripheral neuropathy–related impediments in physical function may also result in a reduced inclination for regular exercise, adding a further metabolic and cardiovascular risk factor.

From a functional perspective, reduced manual dexterity and distal sensation were seen in children and adults on objective testing. Behavioral sciences literature suggests the use of 0.2, 0.5, and 0.8 SDs to demonstrate meaningful clinical differences of small, moderate, and large effect size, respectively. This would suggest that the 0.4 to 0.8 SD deficits observed in the generic health-related QOL and specific neuropathy parent-reported and patient-reported outcomes may have clinical relevance.45-48 However, the clinical significance of the 0.3 to 0.4 SD differences seen in the pediatric functional tasks and 0.4 to 0.6 SD differences in the adult functional tasks are more difficult to interpret. These relatively modest differences might reflect the large inbuilt reserve in pediatric nerves, and the implications of a reduction in this axonal reserve may only become evident with a longer period of observation as the current cohort gets older and potentially accumulates more neurological deficits, as observed in other CCS.49,50 

The stepwise acquisition of new skills during development in children might mean that more significant deficits would present with motor or sensory disability, whereas milder deficits may only present with a failure to achieve their premorbid potential rather than loss of skills. This change in developmental trajectory can be difficult to appreciate. As such, the PRO measures demonstrate global reduction in QOL and more specific impairment in physical function on the PODCI and EORTC questionnaires, suggesting that these deficits on formal testing may be relevant. Other studies have also reported deficits in strength and mobility,8,9,14 balance,51 and postural control52 as well as poorer QOL outcomes53 in CCS. However, the present study links CIPN-specific measures with long-term QOL, providing an important and comprehensive assessment of the association of long-term neuropathy with patient function. Importantly, we have demonstrated the TNS as a significant predictor of adult and pediatric PROs. While deficits evident in functional measures and PROs may be multifactorial, the TNS was specifically designed to capture peripheral neurotoxicity, has been validated against multiple neuropathy measures,54-56 and is correlated with objective neurophysiological measures in CCS, enabling greater confidence in attributing abnormalities to peripheral neuropathy. The TNS is based solely on clinical assessment and has less interindividual variability than neurophysiological testing, making it a valuable screening tool to identify patients at higher risk of disability from peripheral neuropathy.

Limitations

This study had limitations. Although tested several years after completion of their chemotherapy, it is unlikely that participants developed peripheral nerve injury from other causes during this time, given the young age of the cohort. Furthermore, comorbidities and preexisting conditions known to cause nerve injury, such as diabetes, renal failure, and critical illness neuropathy, were specific exclusion criteria. While there is a wide range of time elapsed since completion of treatment among the survivors, the median time since completion of treatment is 8.5 years. Late onset of neurological deficits with an increase in cumulative incidence up to 30 years after completion of therapy has been observed in large databases of CCS49,50 and may be compounded by additional comorbidities that occur as late effects. The administration of different functional and PRO measures for adults and children limited the numbers of participants in some subgroups, including CCS who did not receive any neurotoxic chemotherapy. Further studies are required to develop a greater understanding of CIPN in high-risk CCS, particularly those treated with platinum agents. The functional and PRO measures used in the pediatric participants were not specifically designed for use in CIPN, and only a subset of MABC measures identified functional impairments. As such, the development of responsive, pediatric CIPN–specific outcomes measures would be important for further clinical research into neuroprotective strategies and exercise interventions.

Conclusions


Long-term deficits in clinical, electrophysiological, and functional measures of peripheral neuropathy were common in our young cohort of CCS with concurrent deficits in PRO measures. Multimodal testing with inclusion of objective neurophysiological measures and subjective PRO measures is important to be able to attribute abnormalities to CIPN and determine their clinical relevance. Both the type of neurotoxic agent used and a targeted clinical neurological assessment are important considerations when screening CCS for long-term neuropathy. The effect of CIPN may be greater in the presence of other comorbidities, such as diabetes, and also as CCS get older. Development of standardized, CIPN-specific pediatric assessment tools, further research into the acute development and progression of neuropathy, and delineation of genetic and nongenetic predisposing factors are essential for the development of neuroprotective interventional, and rehabilitative strategies to optimize the long-term QOL for CCS.
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Article Information

Accepted for Publication: February 16, 2018.


Corresponding Author: Susanna B. Park, PhD, Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett St, Camperdown, Sydney, New South Wales 2050, Australia (susanna.park@sydney.edu.au).

Published Online: May 14, 2018. doi:10.1001/jamaneurol.2018.0963

Author Contributions: Dr Kandula had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kandula, Farrar, Cohn, Johnston, Kiernan, Krishnan, Park.

Acquisition, analysis, or interpretation of data: Kandula, Farrar, Cohn, Mizrahi, Carey, Johnston, Kiernan, Park.

Drafting of the manuscript: Kandula, Cohn, Kiernan, Park.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kandula, Park.

Obtained funding: Kandula, Kiernan, Krishnan.

Administrative, technical, or material support: Farrar, Cohn, Mizrahi, Carey, Johnston.

Study supervision: Farrar, Cohn, Kiernan, Park.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by grant APP1114801 from the National Health and Medical Research Council and grant 14/TPG/1-05 from the Cancer Institute of New South Wales as well as by the Royal Australasian College of Physicians and Brain Sciences UNSW of the University of New South Wales Sydney.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We acknowledge Nancy Briggs, BS, MA, PhD (Stats Central, University of New South Wales Sydney, Sydney, New South Wales, Australia), for guidance with statistical analyses. She was not compensated for her work.

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