Chemotherapy-Induced Peripheral Neuropathy 19

Shelby Ubrich, MOT, OTR, and Asfia Mohammed, MOT, OTR

LEARNING OBJECTIVES
After completing this chapter, readers should be able to
■■ Comprehend the etiology and pathology of chemotherapy-induced peripheral neuropathy (CIPN) performance across
the lifespan,
■■ Identify appropriate assessments for determining the negative effect of CIPN on occupational performance during the
evaluation process across the lifespan, and
■■ Apply common occupational therapy interventions to decrease the negative effect of CIPN on occupational perfor-
mance across the lifespan.

KEY TERMS AND CONCEPTS

■■ Chemotherapy-induced peripheral ■■ Dysesthesias ■■ Paresthesias
neuropathy ■■ Epidermis–dermis–fascia ■■ Peripheral neuropathy
■■ Chemotherapy-related technique ■■ Sensory reeducation
neurotoxicity ■■ Exercise

INTRODUCTION One study of 4,179 patients reported that 68.1% of

patients presented with CIPN symptoms within the first
Chemotherapy-induced peripheral neuropathy (CIPN) is a month of receiving chemotherapy, 60% reported CIPN at
commonly experienced adverse side effect that can be caused 3 months, and 30% reported it at 6 months or later (Seretny
by some chemotherapy treatments. Common chemotherapy et al., 2014). These data suggest that CIPN does have the
agents that may cause CIPN include platinum compounds, potential to subside over time for a small percentage of can-
taxanes, vinca alkaloids, thalidomide, and bortezomib (Park cer survivors, but multiple studies have suggested that the
et al., 2013). Peripheral neuropathy is a disease or degenera- prevalence of CIPN is underreported. Numerous research-
tive state of the peripheral nerves that affects motor, sensory, ers and clinicians have called for a gold standard assess-
or autonomic systems, resulting in potential muscle weakness ment to identify the incidence and prevalence of CIPN with
and atrophy, pain, and numbness. CIPN can cause damage to more accuracy (Park et al., 2013).
both motor and sensory nerves, although it is more common CIPN is also reported among pediatric cancer patients,
among sensory nerves (“Peripheral neuropathy,” n.d.). Dam- but its prevalence and impact are not well known (Moore
age to the sensory nerves can lead to symptoms of pares- & Groninger, 2013). In a pilot study assessing use of the
thesias (prickly sensation), dysesthesias (painful sensation), Pediatric-Modified Total Neuropathy Score (Ped–mTNS),
and numbness of the hands and feet in a “glove–­stocking” Gilchrist et al. (2009) indicated that 60% of children
distribution (Park et al., 2013). These sensory symptoms can reported sensory symptoms and 55% reported motor
affect cancer survivors’ functional status and quality of life symptoms. Symptoms observed among pediatric patients
(QoL) by causing ataxia, pain, and severe numbness. include lack of energy, pain, drowsiness, nausea, cough,
The common chemotherapy agents previously listed and lack of appetite (Moore & Groninger, 2013). These
have been shown to affect components of the nervous sys- symptoms can lead to impairments in daily activities, play,
tem, in particular the dorsal root ganglion (DRG). The leisure, and education. The side effects of CIPN are linked
DRG is not protected by the blood–nerve barrier and thus to functional limitations such as difficulty carrying a heavy
is more vulnerable to neurotoxic damage (Park et al., 2013). object, turning and pivoting, picking up a backpack, and
The platinum-derived agents have been shown to cause lifting things from the floor (i.e., from a squat) or down
nerve cell death in the DRG, in turn causing peripheral from overhead. Adults with CIPN report impairments in
neuropathy (Park et al., 2013). common occupations, such as cooking, cleaning, driving,

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 242 PART IV.  Sequelae of Cancer and Interventions Across the Lifespan

sleeping, functional mobility, exercising, and socializing et al., 2012). Loss of proprioception can lead to impaired
(Speck et al., 2012). safety and increased risk of falls because it decreases aware-
The impact of CIPN on occupational performance and ness of foot placement (Moore & Groninger, 2013). Pedi-
engagement in daily activities is severe and may result in atric patients have reported symptoms of CIPN that affect
loss of roles and routines when symptoms limit partici- occupational performance such as fatigue, pain, and mus-
pation. Occupational therapy intervention is essential for cle weakness (Moore & Groninger, 2013).
modifying and adapting everyday activities to minimize Along with sensory and motor impairments, studies
clients’ impairment and increase their participation and have also shown that symptoms of CIPN can adversely affect
performance, leading to an increased QoL. This chapter long-term QoL, psychosocial function, and sleep. Social
describes CIPN across the lifespan and reviews evidence isolation and psychological distress were also reported as
for prevention and occupational therapy treatment. direct impacts of losing engagement in meaningful activi-
ties (Hong et al., 2014). Another study also noted that the
CIPN DEFINING FEATURES estimated reductions in QoL (comprising physical well-
being, social well-being, emotional well-being, and func-
ACROSS THE LIFESPAN tional well-being) among patients undergoing cancer treat-
Chemotherapy-related neurotoxicity is the result of adverse ment who were experiencing CIPN ranged from 15%–20%
side effects that can present in the central nervous system or (Matsuoka et al., 2018).
peripheral nervous system, severely affecting QoL (Taillibert Among pediatric and adult patient populations, the goal
et al., 2016). Such neurotoxicities can lead to dose limitations of pain management is to provide a reduction of symptoms.
and even discontinuation of treatment dependent on the Currently, there are no options that will completely relieve
severity of side effects, which in turn affects the efficacy of motor or sensory symptoms of CIPN (Moore & Groninger,
treatment (Taillibert et al., 2016). The impact on the periph- 2013). Table 19.1 presents some options to manage symp-
eral nervous system can be manifested in its three divisions: toms of CIPN (Moore & Groninger, 2013).
(1) sensory, (2) motor, and (3) autonomic (Gilchrist, 2012).
Sensory and motor symptoms are described in Exhibit 19.1.
Patients may also experience a loss of proprioception, spatial OCCUPATIONAL THERAPY’S ROLE
awareness, and orientation within the body (Moore & Gron- IN MANAGING CIPN ACROSS
inger, 2013). The presentation of CIPN has been reported to THE LIFESPAN
be very consistent across the lifespan. Both pediatric and adult
patients experience similar symptoms; however, pediatric Because of the complex presentation of CIPN, occupational
prevalence and treatment have not been widely investigated. therapy intervention can vary from patient to patient. Stud-
The severity of symptoms depends on the dosage and ies have reported that occupational therapy intervention is
regimen of administration of the chemotherapies known primarily focused on adaptation and remediation through
to cause CIPN. In many cases, when the presence of CIPN sensory and functional activities (Pergolotti et al., 2016).
is noted, the dosage is decreased or the regimen is altered
to prevent increased severity of CIPN symptoms. Neuropa- Occupational Profile
thy-related risk factors can also affect the severity of symp-
toms, such as underlying neuropathy, alcohol usage, folate Occupational therapy intervention for patients experienc-
or Vitamin B12 deficiency, and hereditary sensory–motor ing CIPN begins with developing an occupational profile to
neuropathy (Taillibert et al., 2016). understand the extent and experience of the impairments
Both sensory and motor symptoms of CIPN have been (American Occupational Therapy Association [AOTA],
reported to negatively affect functional performance. 2017). To compile a robust occupational profile, occupa-
Patients with metastatic breast cancer described diffi- tional therapy practitioners collect information to iden-
culty with walking, socializing, driving, standing, cook- tify patients’ concerns related to occupations, meaningful
ing, climbing stairs, maintaining balance and steadiness, activities, aspects of the environment or client factors lim-
opening containers, holding onto objects, flipping pages iting engagement, and occupational history that has been
of paper, fastening jewelry, exercising, and sleeping (Speck affected by CIPN (AOTA, 2014, 2017).

EXHIBIT 19.1. CIPN Symptoms

SENSORY SYMPTOMS MOTOR SYMPTOMS
■■ Loss of intervention in a glove and stocking distribution ■■ Decline in muscle strength
■■ Tactile allodynia (pain from stimuli not typically painful [heightened sensitivity]) ■■ Atrophy
■■ Cold allodynia ■■ Balance deficits
■■ Hypersensitivity ■■ Gait abnormalities
■■ Loss of both vibration sensitizing and deep tendon reflexes ■■ Decreased manual dexterity
■■ Pain that is described as burning, tingling, painful numbness, or electric
■■ Decreased proprioception
■■ Impaired spatial awareness and orientation within the body
Note. CIPN = chemotherapy-induced peripheral neuropathy.

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 CHAPTER 19.  Chemotherapy-Induced Peripheral Neuropathy 243

TABLE 19.1.  Therapeutic Symptom Management of CIPN

AGENT POPULATION MANAGEMENT
Gabapentin Adult and pediatric Has been used effectively to treat neuropathic pain
Pyridostigmine Adult and pediatric Assists with neuropathy-related bowel immotility
Nortriptyline Adult (toxic even in low doses for pediatric Works by blocking the reuptake of serotonin and norepinephrine
patients) in the pain-modulating system within the central nervous
system
Opioids: morphine, oxycodone, Adult and pediatric Can help with painful neuropathies to help manage pain until
and fentanyl other agents are effective
Tramadol (not for pediatrics)
Acupuncture Adult and pediatric ■■ Found to improve sensation and gait, resulting in decreased
analgesic use
■■ Low risk of adverse events when provided by a trained
professional
Transcutaneous nerve stimulation Adult and pediatric Improves neuropathy symptoms, including numbness, pain, and
allodynia among diabetic neuropathy patients
Physical rehabilitation Adult and pediatric ■■ Improves functional outcomes by increasing fine motor
dexterity, gait and balance stability, and engagement in ADLs
and IADLs
■■ Helps pediatric clients continue to work to meet appropriate
developmental milestones
Note. ADLs = activities of daily living; CIPN = chemotherapy-induced peripheral neuropathy; IADLs = instrumental activities of daily living.

Analyzing Occupational Performance as recommended by Davies (2013). Education and training

can include incorporating energy conservation techniques
After establishing a robust occupational profile, occupational to enhance occupational performance as well as establish-
therapy practitioners analyze clients’ current occupational ing routines to maximize time management and participa-
performance: They observe clients’ performance in mean- tion. Most important, occupational therapy intervention
ingful activities, administer assessments to identify and mea- can include adapting tasks and environments to optimize
sure the level of impairments and skills, create goals with the occupational performance in desired occupations and
client to address desired outcomes, and determine the mode activities. Patients have reported that functional engage-
of intervention on the basis of best practice (AOTA, 2014). ment decreases their CIPN symptoms (Speck et al., 2012).
Assessments that can be conducted to establish a baseline Occupational therapy practitioners may also find them-
include functional assessments such as the Functional Inde- selves needing to advocate for services that may benefit can-
pendence Measure (Deutsch et al., 1996), Activity Measure for cer survivors with CIPN. For example, practitioners may need
Post-Acute Care (Jette et al., 2014), range of motion (ROM), to initiate a consultation for counseling services if the client
manual muscle testing, various sensory tests, and the Func- is struggling with anxiety or stress that is affecting occupa-
tional Assessment of Cancer Therapy–, as in Chapter 17– tional performance. Anxiety and stress can exacerbate CIPN
General (FACT–G; Cella et al., 1993). The FACT–G measures symptoms and require appropriate inter­ vention (Davies,
a patient’s functional, social, physical, and emotional well-be- 2013). Occupational therapy intervention may also focus on
ing (Cella et al., 1993). Other important assessments that can empowering clients to obtain resources to enhance occupa-
provide insight into the patient’s daily routine include the Role tional participation and increase well-­being (AOTA, 2014).
Checklist (Oakley et al., 1986) and the Model of Human Occu- Occupational therapy practitioners establish treatment
pation Screening Tool (Parkinson et al., 2001). The established plans that are directed by the selection and implementa-
baseline then allows occupational therapy practitioners to tion of various approaches to intervention (AOTA, 2014).
fully see the impact of the client’s symptoms on their engage- Approaches to intervention include health promotion, reme-
ment or lack of engagement in ADLs or IADLs. diation, restoration, maintenance, modification, and preven-
tion. Occupational therapy practitioners use these approaches
Intervention to select appropriate practice models, frames of reference, or
treatment theories to guide intervention (AOTA, 2014).
Occupational therapy intervention may include therapeutic One example of restorative intervention that has been
use of occupations and activities, preparatory methods and used to treat CIPN includes stimulation to promote nerve
tasks, education and training, advocacy, and group inter- conduction through the use of Kinesio Taping® to increase
ventions (AOTA, 2014). Occupational therapy sessions blood flow and nerve conduction to the extremities (Lee
may incorporate preparatory activities, such as aerobic & Mohammed, 2018). Other interventions shown to have
exercise, thermal therapy, stretching, and strengthening, positive benefits in preventing secondary musculoskeletal

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 244 PART IV.  Sequelae of Cancer and Interventions Across the Lifespan

impairments, in turn bringing patients closer to their func- population (school-age children ages 5–18 years). Alter-
tional baseline, include active ROM exercises and strength- natively, in the pediatric population, the CTCAE was for-
ening or simple active movement (Kim et al., 2015). merly the most commonly used measure for peripheral
Promoting clients’ awareness through education about neuropathy (Gilchrist et al., 2009). However, the CTCAE
CIPN before chemotherapy is initiated can provide sub- is very extensive and broad in its scope and lacks the ability
stantial benefits. Because one of the factors used to man- to identify the specific characteristics of CIPN. The Ped–
age the severity of CIPN is the dosage and administration mTNS identifies deficits specifically related to pin sensibil-
of the aggravating chemotherapy, it is very important that ity, vibration sensation, muscle strength, and deep tendon
clients are aware of the signs of CIPN. Recognizing the reflexes (Gilchrist et al., 2009).
signs and symptoms of CIPN can drive clients to report After using appropriate assessments to gather necessary
any symptoms to their oncologist right away, which may information regarding clients’ functional capacity and defi-
lead to dosage reduction immediately. This limits the pro- cits, occupational therapy practitioners should develop an
longed exposure to the problematic chemotherapy agent, intervention plan to address clients’ needs for management
decreasing the severity of CIPN among clients treated with of symptoms as a result of CIPN for improved functional
the aggravating chemotherapies. engagement in all occupations and improved QoL. Reas-
Modification and adaptation of therapeutic occupa- sessment of symptoms and occupational performance is
tions and activities have been shown to improve functional completed intermittently, and appropriate revisions to the
outcomes through the increase of functional participation intervention plan are made throughout treatment.
(Speck et al., 2012). Modifications can include building up Client factors such as neuromusculoskeletal and move-
utensil grips to compensate for decreased grip strength, ment-related functions are traditionally measured through
wearing clothing that is not a noxious stimulus, or sit- routine assessment of ROM, manual muscle testing, grip
ting down to engage in activities previously performed by strength, and pinch strength. The Nine Hole Peg Test
standing to increase safety in response to numbness in (Mathiowetz et al., 1985) provides a more objective measure
lower extremities. of finger dexterity that can demonstrate progress or regres-
Environmental modifications can be made as well. Some sion over time, which allows for improved prognostication
environmental modifications include reorganizing cabinets of the outcome of functional performance of tasks (Kim et
to place important items within reach; removing fall haz- al., 2015; Wang et al., 2015). Sensory function is measured
ards such as throw rugs, clutter, and wires; and adding light by presence or absence of pain; clients’ ability to recognize
to dark areas that the client frequently visits. Community light touch or deep touch, sharp or dull sensations, and tem-
tasks can also be modified. For example, clients can use an perature; stereognosis; and proprioception (Kim et al., 2015).
electric scooter in a store if they are not able to tolerate walk- The Semmes Weinstein Monofilament Test (Weinstein,
ing around during shopping or obtain a handicap parking 1993) can be used to measure a more precise degree of
sticker to limit the distance from the parking lot to the store. sensory loss and is very sensitive to comparison of sensory
loss with the return of sensations. The Moberg Pickup Test
Commonly Used Assessments Specific (Ng et al., 1999) is even more functionally representative
to Sequelae of fine motor dexterity and sensation because it uses small
everyday objects to be picked up, held, manipulated, and
Although there is no gold standard assessment tool for identified.
CIPN among adults, occupational therapy practitioners More specifically defined functional assessments of
can use a limited number of assessments to fully identify patient perception include the Disabilities of the Arm,
clients’ impairments to develop client-centered interven- Shoulder, and Hand (DASH; Hudak et al., 1996) and the
tions that support functional performance. Some com- Manual Ability Measure (MAM; Chen et al., 2005; Pergo-
monly used assessments to measure client factors include lotti et al., 2016). These assessments can be used as precur-
■■ ROM; sor and distinguishing tools for intervention focus because
■■ Manual muscle testing; they use practical, everyday functional tasks to identify
■■ Grip strength; clients’ perceived ability to perform such tasks and further
■■ Pinch strength; reflect with actual performance in treatment sessions. The
■■ Sensation; DASH and MAM present the opportunity for increased
■■ Various assessments of the arm, shoulder, and hand; awareness, self-initiated problem solving, and identifica-
■■ Brief Fatigue Inventory (MD Anderson Cancer Center, tion of possible modifications facilitated by the occupa-
2018); and tional therapy practitioner (Chen et al., 2005; Hudak et al.,
■■ Pittsburgh Sleep Quality Index (Buysse et al., 1989; see 1996; Pergolotti et al., 2016).
Table 19.2). Global and specific mental functions are also client fac-
Several grading systems also are used clinically to clas- tors to be assessed and accounted for through the typical
sify the severity of CIPN, such as the National Cancer Insti- interview process, including the use of specific measures
tute’s Common Terminology Criteria for Adverse Events related to fatigue and sleep. The side effects of CIPN clients
(CTCAE; Brewer et al., 2016) and the Total Neuropathy experience and the extent of such interference can greatly
Score (TNS; Gilchrest et al., 2009). In a review by Cavaletti affect their state of fatigue and sleep, which, in turn, affects
et al. (2007), the TNS showed more sensitivity to changes their functional status in daily occupations. The Brief Fatigue
in CIPN. The Ped–mTNS is currently noted in the litera- Inventory (MD Anderson Cancer Center, 2018) can be used
ture for assessing peripheral neuropathy in the pediatric to assess the severity of fatigue experienced as a result of

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 CHAPTER 19.  Chemotherapy-Induced Peripheral Neuropathy 245

TABLE 19.2.  CIPN Assessment Tools

ASSESSMENT BRIEF DESCRIPTION
ROM Evaluation of active or passive ROM
Manual muscle testing Evaluation of strength
Jamar dynamometer and pinch gauge ■■ Jamar dynamometer measures grip strength
(Bechtol, 1954) ■■ Pinch gauge measures tip, key, and palmar pinch
Nine Hole Peg Test ■■ Assesses finger dexterity
(Mathiowetz et al., 1985; Wang et al., ■■ Involves picking up, holding, and manipulating pegs for placement into and removal from board as
2015) fast as possible
Moberg Pickup Test ■■ Assesses finger dexterity and sensation
(Ng et al., 1999) ■■ Involves picking up, holding, manipulating, and identifying small objects
■■ Timed, quick, and inexpensive
Sensation ■■ Pain
■■ Light touch versus deep touch
■■ Sharp versus dull
■■ Hot versus cold
■■ Stereognosis
■■ Proprioception
Semmes Weinstein Monofilament Test ■■ Set of monofilaments that vary in thickness and diameter and are used to map out sensory loss
(Weinstein, 1993) ■■ The results are useful in comparing sensory loss with the return of sensations
Disabilities of the Arm, Shoulder, and Hand ■■ Questionnaire asks about symptoms and ability to perform certain activities
(Hudak et al., 1996) ■■ 30 items
Manual Ability Measure ■■ Questionnaire on perceived ease or difficulty that a person may experience when performing
(Chen et al., 2005) unilateral and bilateral ADLs
■■ 20-item and 36-item versions scored on a 4-point scale
Brief Fatigue Inventory Short scale that quickly assesses severity of fatigue experienced by cancer patients as well as fatigue’s
(MD Anderson Cancer Center, 2018) impact on patients’ ability to function over the previous 24 hours
Pittsburgh Sleep Quality Index ■■ Used to measure adults’ quality and patterns of sleep
(Buysse et al., 1989) ■■ Differentiates “poor” from “good” sleep quality by measuring 7 areas (subjective quality, latency,
duration, habitual efficiency, disturbances, medications, and daytime dysfunction) over the past month
Note. ADLs = activities of daily living; CIPN = chemotherapy-induced peripheral neuropathy; ROM = range of motion.

various treatment symptoms, such as CIPN, and the Pitts- strategies. See Table 19.3 for a brief description of proposed
burgh Sleep Quality Index (Buysse et al., 1989) measures interventions.
the quality and patterns of sleep. Therefore, it is important
to be familiar with many assessments to fully address clients’ Awareness of CIPN
current needs for improved management of CIPN and func-
tional status. The promotion of increased awareness pertains to insight
into clients’ current functional status and limitations, with
Occupational Therapy Interventions emphasis on safe performance of tasks in various environ-
Focused on Sequelae ments. Individuals living with CIPN are at a significantly
greater risk of falling and injuring themselves secondary to
Occupational therapy intervention requires a multifaceted impaired sensation, proprioception, and muscle strength
approach when addressing cancer survivors’ functional and control (Gewandter et al., 2013; Holz et al., 2017; Veale,
abilities and limitations affected by CIPN. No one interven- 2016). Thus, it is particularly important to be fully aware
tion approach is best or suitable to meet the needs of every of one’s surroundings at all times with respect to flat sur-
individual living with CIPN. Some commonly used inter- faces without and with transitions to uneven terrain, which
ventions to manage the impact of CIPN include increased are more difficult to negotiate with impaired sensation or
awareness of deficits and safety concerns, adaptation and strength (Holz et al., 2017; MD Anderson Cancer Center,
compensatory strategies, neuromuscular electrical stim- 2017).
ulation, sensory reeducation, use of compression stock- Occupational therapy practitioners may need to
ings, exercise, Kinesio Taping, and education about coping make modifications to the environment, such remov-
ing tripping hazards (e.g., loose rugs, extension cords,

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 246 PART IV.  Sequelae of Cancer and Interventions Across the Lifespan

TABLE 19.3.  CIPN Interventions

INTERVENTION BRIEF DESCRIPTION
Increased awareness ■■ Self-awareness and insight into current functional status and limitations
■■ Awareness of skin integrity
■■ Safe performance in various environments
Adaptation and compensatory strategies ■■ Modifications to environment, tools, or techniques, with emphasis on task analysis
Neuromuscular electrical stimulation ■■ Transcutaneous electrical nerve stimulation units use electrical fields to directly affect the transmission
of pain
■■ Evidence is limited for the cancer population
Sensory reeducation ■■ Various textures
■■ Vibration
■■ Tactile input
■■ Proprioception
Compression stockings ■■ Reduce pain
■■ Provide more tactile input
Exercise ■■ Improves functional strength for safe performance of functional mobility and participation in all
occupations
Kinesio Taping ■■ Alleviates compression of nerves
■■ Provides pain relief
Coping strategies ■■ Mindfulness
■■ Coping skills
■■ Meditation
■■ Yoga
■■ Diaphragmatic breathing
■■ Sleep hygiene
Note. CIPN = chemotherapy-induced peripheral neuropathy.

unnecessary obstacles) and adding appropriate dura- deficits and active problem solving to improve functional
ble medical equipment (e.g., shower chair, tub transfer capacity and, ultimately, performance of occupations.
bench, bedside commode), rails, or grab bars in areas of Adaptations or modifications can consist of adaptive equip-
concern for loss of balance, such as transitions within ment from built-up foam tubing, nonslip materials, button
the home and bathrooms (Holz et al., 2017; Pergolotti et hooks, rocker knives, and the use of other adaptive tools
al., 2016). Additional considerations include daily skin to perform functional tasks to maintain independence as
checks for detection of any cuts or injuries that may put well as the use of assistive devices during such tasks for
clients at increased risk for infection because of impaired improved balance and overall safety (Kim et al., 2015;
sensation. Practicing proper hygiene and wearing loose Pergolotti et al., 2016; Speck et al., 2012).
cotton socks with protective shoes for good support are The implementation of coping skills along with envi-
also important for maintaining skin integrity and safety ronmental modifications can further support task analysis.
with balance (MD Anderson Cancer Center, 2017). Self-management strategies are effective in reducing the
Heightened sensory experiences, such as severe pain, impact of CIPN symptoms during engagement in occupa-
and significantly decreased sensory experiences, such as tions (Holz et al., 2017; Speck et al., 2012). Some reported
numbness, can greatly affect functional independence self-management strategies include
and safety for individuals living with CIPN. Compression ■■ Focus on movement to reduce symptoms,
stockings have been shown to decrease the sensation of ■■ Attitude awareness,
pain (e.g., pins and needles, burning) as well as improve ■■ Mindfulness,
sensory feedback, allowing for improved functional inde- ■■ Meditation,
pendence with occupations (Holz et al., 2017). ■■ Yoga,
■■ Diaphragmatic breathing, and
Modifying techniques and the environment ■■ Sleep hygiene.
Task analysis is key to breaking down tasks into smaller
parts, making modifications to the techniques clients are
Establishing and restoring function
using, and altering the environmental components for Neuromuscular reeducation and sensory reeducation
functional independence. Adaptations and compensatory are intervention approaches used for restoration of func-
strategies evolve from increased awareness of functional tion. Although there is limited evidence for the cancer

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 CHAPTER 19.  Chemotherapy-Induced Peripheral Neuropathy 247

population, making this is an area of further opportunity FIGURE 19.1. EDF technique for CIPN on toes.
for research, the use of neuromuscular electrical stimula-
tion (e.g., transcutaneous electrical nerve stimulation) can
help with chronic pain related to CIPN when it is resistant
to conservative treatment. It can be administered by an
occupational therapist as well as many other medical pro-
fessionals (Holz et al., 2017; Kim et al., 2015; Taillibert et
al., 2016; Veale, 2016). Sympathetic nerve blocks and sym-
pathetic neurolysis, which is delivered by an injection and
spinal cord or peripheral nerve stimulators, are permanent
implantable devices administered by a physician. Because
they are more invasive interventions, they are less com-
monly seen (Kim et al., 2015).
Sensory reeducation focuses primarily on desensitiza-
tion and restoration of sensory function with exposure to
various textures, vibration, tactile input, and propriocep-
tion. For instance, various textures are introduced at areas
of sensory loss and areas of normal sensation to allow the
brain to process and compare the tactile input for sensory
retraining. As mentioned previously, compression stock-
ings can also help increase tactile input for improved sen-
sory feedback as well as decrease pain (Holz et al., 2017).
Increased attention to tasks using vision to provide the
brain with necessary feedback is also recommended sec-
ondary to impaired sensation.
The literature shows the most promising support for use
Note. CIPN = chemotherapy-induced peripheral neuropathy; EDF =
of exercise, which has been reported to consistently improve
epidermis–dermis–fascia.
symptoms of CIPN and overall functional well-being (Holz
Source. A. Mohammed. Used with permission.
et al., 2017; Kim et al., 2015; Speck et al., 2012; Taillibert
et al., 2016; Veale, 2016). Exercise aimed at improving
active ROM, strength, balance, stability, and posture has
a restorative focus as it relates to functional participation FIGURE 19.2.
EDF technique for CIPN: Applying tape
in occupation (Kim et al., 2015). Exercise should be noted over the back of toes.
as improving weakness, fatigue, and other neuromuscular
deficits as a result of CIPN symptoms rather than as having
a direct impact on the symptoms of CIPN (Veale, 2016).
Thus, it can be concluded that exercise has an impact on
functional independence, QoL, and the reduction of falls
(Veale, 2016).
Kinesio Tape has been used to minimize the effects of
certain neurologic conditions, such as cerebral palsy (Kine-
sio University, 2013). The Kinesio Tex Gold Finger Print,
in comparison with the Kinesio Tex Classic, was designed
to be particularly effective with circulatory, lymphatic, and
neurological treatments. This is possible because the finger-
print advancement allows for a more microtargeted finger-
print pattern in the adhesion of the tape.
The epidermis–dermis–fascia technique (EDF) is
a dermal taping technique that may lead to positive
responses in the brain (Kinesio University, 2013). It has
been used to counter certain neurologic conditions such
as cerebral palsy. The EDF technique for management of
CIPN involves thinly cut strips placed superficially with
0%–5% tension anchored on the distal aspect of the limb
traveling along the affected area proximally. See Figures
19.1–19.3 for a visual of this EDF technique. The EDF
technique is thought to lift the epidermal layers, provid-
ing increased blood flow among the epidermis, dermis, Note. CIPN = chemotherapy-induced peripheral neuropathy; EDF =
and fascia and decreasing the noxious sensation to the epidermis–dermis–fascia.
affected areas (Lee & Mohammed, 2018). Although no Source. A. Mohammed. Used with permission.
formal studies have been conducted on the use of this

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 248 PART IV.  Sequelae of Cancer and Interventions Across the Lifespan

EDF technique for CIPN on bottom of technique for CIPN management, patients have reported
FIGURE 19.3. that the presence of the tape has allowed them to tol-
foot.
erate functional mobility and grooming while standing
(Lee & Mohammed, 2018). Further research on the use
of Kinesio Tape with CIPN management is warranted.
Case Example 19.1 describes the use of kineseotaping to
manage CIPN with one adult patient with leukemia, and
Case Example 19.2 describes CIPN management of one
pediatric cancer survivor.

SUMMARY
CIPN is a common, recognizable side effect of cancer
treatment that requires proper identification of its func-
tional impact on occupational performance and engage-
ment in occupations for clients to achieve independence
and fulfillment. Although a gold standard assessment tool
is yet to be identified, skilled clinicians can implement a
variety of assessments and modalities to improve clients’
QoL.
Occupational therapy practitioners have a unique
opportunity to comprehensively identify how CIPN
affects clients’ roles and routines from a holistic approach
and recognition of physical, sensory, functional, and
psychological components. These client factors are col-
lectively addressed by a compilation of modes of interven-
Note. CIPN = chemotherapy-induced peripheral neuropathy; EDF =
tion, including modification, restoration, and promotion
epidermis–dermis–fascia.
of awareness. Although the negative side effects of CIPN
Source. A. Mohammed. Used with permission.
may improve over time with a multifaceted approach of
interventions, the overall goal is symptom management

CASE EXAMPLE 19.1. MRS. MARTIN: LIVING WITH

AND MANAGING CIPN

Occupational profile hospitality apartment that is one level with no steps

to negotiate and with access to a walk-in shower. Mrs.
Mrs. Martin is a 61-year-old woman presenting to Martin has no durable medical equipment (DME) of
occupational therapy services with a cancer diag- her own; however, she does have a wheelchair avail-
nosis of myelodysplastic syndrome with a planned able to her at the hospitality home for use during
haploidentical stem cell transplant (SCT), which is a her stay.
type of allogeneic transplant using cells from a half-
matched donor. She is admitted to the inpatient unit Analysis of occupational performance
in acute care for her chemotherapy induction 6 days
before her scheduled SCT. Mrs. Martin is referred to At initial evaluation through informal questioning
occupational therapy services for participation in an and interviewing, Mrs. Martin was noted to be inde-
exercise group during her prolonged hospitalization. pendent with all functional mobility and ADLs and
Before admission, she was living with her mother and reported no complaints with IADLs. The only com-
was independent with all ADLs in the home. plaint she reported was some discomfort in her knees
Mrs. Martin is a retired schoolteacher and reports with mobility secondary to comorbid arthritis. She
her hobbies as playing board games and doing puz- presented with no impairments in all areas of client
zles. Her home is 160 miles from the hospital, and she factors and performance skills, so the occupational
arrived with her mother in their own car. On discharge, therapist initially took preventive and maintenance
she will need to stay locally for 100 days to ensure approaches in establishing the intervention plan for
continued recovery and good health, with immediate Mrs. Martin, given her treatment course and expected
availability to return to the hospital should any com- prolonged hospitalization.
plications arise. At discharge, she will be staying at a
(Continued)

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 CHAPTER 19.  Chemotherapy-Induced Peripheral Neuropathy 249

CASE EXAMPLE 19.1. MRS. MARTIN: LIVING WITH

AND MANAGING CIPN (Cont.)
Intervention process (EDF) technique with Kinesio Tape for alleviation of
debilitating pain from CIPN.
The occupational therapist initially provided educa- The occupational therapist applied a test strip of
tion to address the importance of consistent out-of-bed Kinesio Tape for 24 hours to clear Mrs. Martin of any
activity (6–8 hours per day) and continued participa- skin integrity concerns before proceeding with the Kine-
tion in habits, roles, and routines in the hospital envi- sio Tape technique for CIPN. No skin integrity concerns
ronment as similarly and consistently as possible to were noted, so the therapist applied Kinesio Tape to
those of her home environment. The therapist also pro- Mrs. Martin’s BLEs (feet) for improved comfort and pain
vided initial teaching of an upper-extremity home exer- relief from CIPN, using the EDF technique with no ten-
cise program that included resistance exercise bands sion. After cleansing and drying both feet, the therapist
to help Mrs. Martin maintain her current strength and applied thin strips of fingerprint Kinesio Tape from the
endurance and prevent deconditioning with extended anterior position, anchored on the nail beds and trav-
hospitalization. eling along the affected area proximally, and secured at
The occupational therapist provided specific edu- the posterior position of the heel with no tension on the
cation for performance of resistive exercises only as dorsum of each foot.
appropriate with regard to platelet count, with comple- Mrs. Martin was educated on having Kinesio Tape
tion of exercises with active range only and no resis- removed if it was bothersome to any degree, includ-
tance when platelets dropped below 20,000 platelets ing itching or redness; instruction was also given
per microliter, as tolerated, because resistive exercises for slow, controlled removal and use of adhesive
are contraindicated below this level. Mrs. Martin was to remover if needed. Fortunately, Mrs. Martin presented
perform the home exercise program independently on a with no complaints before, during, or after taping
daily basis three times per day, 10 repetitions each time, throughout use of the treatment intervention during
as tolerated. Group exercise class was also offered, and hospitalization.
Mrs. Martin was encouraged to attend three times per The occupational therapist first trialed the EDF
week at 1-hour durations for improved strength, endur- technique with Kinesio Tape on the dorsum aspect of
ance, and quality of life with her prolonged medical Mrs. Martin’s feet, before further trialing it on the ven-
needs and hospitalization and the accompanying risk tral aspect of her feet, to identify the effectiveness of the
for deconditioning. intervention to the most problematic area, given that
Mrs. Martin had reported that her pain was most sig-
Occupational therapy interventions focused on nificant at the dorsum aspect compared with the ven-
sequelae tral. She was instructed to wear any given application
Mrs. Martin was seen for 1–2 individual treatment for only 5 days at a time and to ensure proper cleans-
sessions per week during her first month of hospital- ing and drying of skin (with no use of lotions) before
ization because she was not attending the group exer- reapplication of Kinesio Tape while performing routine
cise sessions and was mostly observed performing skin checks.
ADLs and functional mobility with supervision and On follow-up, Mrs. Martin reported significant
fair compliance with out-of-bed activity. These individ- improvement in functional participation in mobility
ual treatment sessions focused on therapeutic exercise, and ADLs in her hospital room, secondary to decreased
compensatory strategies, positioning, and DME recom- pain in BLEs with use of Kinesio Tape with the EDF
mendations (i.e., bedside commode, tub bench, hand- technique. The occupational therapist provided fam-
held showerhead) to increase Mrs. Martin’s safety and ily training during the second and third applications
independence with ADLs. secondary to effectiveness of the intervention to allow
At about the 1-month mark, Mrs. Martin presented for continued implementation and improved func-
with decreased out-of-bed tolerance and increased tional independence with ADLs and functional mobil-
need for assistance, requiring a rolling walker and ity during hospitalization in preparation for discharge
increased assistance with ADLs secondary to significant to home. Despite improvements in pain management
complaints of neuropathic pain in her bilateral lower and functional performance, recommendations for
extremities (BLEs) affecting her functional mobility for DME (i.e., bedside commode, shower chair, grab
participation in ADLs. Thus, treatment interventions bars, a handheld showerhead) were still warranted in
became more focused on sensory reeducation with the home setting because of fall safety concerns and
exposure to various textures, positioning with elevation fatigue management needs affected by the presence of
of BLEs, and introduction of epidermis-dermis-fascia CIPN.

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 250 PART IV.  Sequelae of Cancer and Interventions Across the Lifespan

CASE EXAMPLE 19.2. KELLY: CHILDHOOD WITH CIPN

Kelly is an 11-year-old girl with a history of acute lym- settings. This would also increase Kelly’s confidence in
phoblastic leukemia who has not achieved remission standing and ease her ability to complete her ADL rou-
despite treatment. Her course of treatment was compli- tine, especially those tasks requiring the use of her UEs
cated by severe colitis and Clostridium difficile infection overhead and with reach out of her base of support. 
as well as strokelike symptoms associated with metho- An AFO was fitted with the assistance of an orthotist,
trexate toxicity. Kelly’s treatment course also included and a rolling walker was provided. Kelly and her fam-
high doses of vincristine. On initial evaluation, she was ily were educated on effects of high-dose chemotherapy
living with her parents and three older sisters, was com- agents, the benefits of assistive devices, and the impor-
pleting some homeschooling, and reported enjoying art tance of Kelly’s consistent engagement in therapeutic
and video games; however, she reported difficulty engag- interventions and ADL routines to improve her safety;
ing in leisure activities.  decrease falls risk; and aid in consistent improvement
Kelly presented with gross weakness (“fair minus” or to strength, balance, and endurance. This required fre-
3 minus/5 at shoulders, and “good minus” or 4 minus/5 quent reeducation because Kelly was highly sedentary
distally to upper extremities [UEs]). She had decreased and often received the occupational therapist in the
dorsiflexion to her right foot, significant tightness with side-lying position in bed. 
shortening of her hamstrings, and in long sitting was Kelly displayed significant improvements in postural
unable to achieve full extension of her right knee. Kelly alignment, standing balance, functional mobility, and
had a recent fall at home and was fearful of mobility endurance with just the initiation of an AFO. However,
in the hospital setting with her occupational therapist. outside her therapy sessions, she resisted using her AFO
She became very aggravated and anxious on initiation and completely refused to use a rolling walker. In this
of occupational therapy sessions, often working herself particular case, family dynamics also played a role in
up to the point of throwing up in an attempt to avoid consistency of engagement in interventions because both
mobility. parents worked full-time and were caring for another
Initial sensation impairments were difficult to assess child with a chronic illness. Focus shifted to improving
in relation to her behaviors because she would not proprioceptive input to Kelly’s feet (e.g., consistent use of
directly communicate or answer the occupational ther- sneakers during mobility both in and outside the home),
apist’s questions. Impairments noted were based on mirror therapy for visual input to postural alignment
the functional impairments observed, which included and step pattern, and high-level weight-bearing activi-
poor functional mobility, fair static and poor dynamic ties (e.g., dancing, Hula-Hoop, pushing activities).
standing balance, impaired postural alignment, fear of Cotreatments were completed occasionally with phys-
mobility, decreased engagement in self-care activities, ical therapy to maximize consistency and f­ollow-through.
and impaired ability to reach overhead (which included Kelly became resistive to this after two sessions as well,
maintaining standing balance with attempt to brush her reporting, “I don’t want to do anything fun, just let me do
hair). my exercises and be done.” She would no longer engage in
Kelly also displayed significant body image impair- leisure activities as part of therapeutic intervention. Focus
ments related to treatment interventions. She was resis- again shifted to dynamic movements and ability to transi-
tive to adaptive equipment, including an ankle–foot tion from tailored sitting on the floor to standing to allow
orthosis (AFO) and assistive device for mobility. She was engagement in play with her sisters in her home environ-
very self-conscious about engagement in ADL routines ment. Kelly was again fearful and aggressive in this area,
near the bathroom mirror because her hair was falling but with consistency from the occupational therapist, she
out. was able to improve from maximum assistance to standing
Kelly also displayed further symptoms associated from a seated position to minimal assistance without use
with peripheral neuropathy to bilateral hands, including of the AFO. 
impaired ability to hold a writing tool, impaired digit At this stage, Kelly’s treatment remains largely out-
opposition, decreased gross grasp, impaired fine motor patient, and because of the previously mentioned fam-
control, and impaired ability to maintain a hand hold ily dynamics, consistency in engagement in outpatient
on heavy objects (e.g., a full cup). Again, despite noted therapy has remained minimal. The occupational ther-
impairments, she was resistive to formal assessment.  apist sees Kelly intermittently during inpatient admis-
Despite multiple impairments and a long cancer treat- sions, and Kelly remains grossly at minimal assist level
ment, Kelly was new to therapy services and remained for a basic self-care routine; however, she continues to
difficult to engage, although multiple occupational ther- display impairments in the areas of gross motor move-
apists met with her to see whether she would respond ments (jumping, skipping, running) and fine motor
differently on the basis of personality and rapport. coordination (impaired ability to hold a writing utensil,
In an effort to maximize safety and fall prevention in difficulty cutting food, and impaired digit opposition).
the setting of poor patient engagement, the focus was She also remains a high falls risk associated with lim-
initially on fitting and trialing the AFO and on using itations in balance, postural alignment, and endurance
adaptive devices for functional mobility to allow Kelly associated with compensatory movements related to
to engage in mobility in both home and community peripheral neuropathy and right foot drop.

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 CHAPTER 19.  Chemotherapy-Induced Peripheral Neuropathy 251

because most clients have some degree of residual side Gilchrist, L. S., Tanner, L., & Hooke, M. C. (2009). Measuring
effects that influence their functional performance and ­chemotherapy-induced peripheral neuropathy in children: Dev­
QoL over the lifespan. elopment of the Ped-mTNS and pilot study results. Rehabilita­
tion Oncology, 27(3), 7–15.
REFERENCES Holz, S. C., Wininger, Y. D., Cooper, C., & Smith, S. R. (2017).
Managing neuropathy after chemotherapy in patients with can-
American Occupational Therapy Association. (2014). Occupa- cer. Archives of Physical Medicine and Rehabilitation, 98, 605–
tional therapy practice framework: Domain and process (3rd 607. https://doi.org/10.1016/j.apmr.2016.08.461
ed.). American Journal of Occupational Therapy, 68(Suppl. 1), Hong, J. S., Tian, J., & Wu, L. H. (2014). The influence of che-
S1–S48. https://doi.org/10.5014/ajot.2014.682006 motherapy-induced neurotoxicity on psychological distress
American Occupational Therapy Association. (2017). AOTA and sleep disturbance in cancer patients. Current Oncology, 21,
occupational profile template. American Journal of Occupa­ 174–180. https://doi.org/10.3747/co.21.1984
tional Therapy, 71, 7112420030. https://doi.org/10.5014/ajot.​ Hudak, P., Amadio, P. C., Bombardier, C., & Upper Extrem-
2017.716S12 ity Collaborative Group.  (1996). Development of an
Bechtol, C. O. (1954). Grip test: The use of a dynamometer with upper extremity outcome measure: The DASH (Disabili-
adjustable handle spacings. Journal of Bone and Joint Surgery, ties of the Arm, Shoulder, and Hand). American Journal of
36A(4), 820–824. Industrial Medicine, 29, 602–608. https://doi.org/10.1002/
Brewer, J. R., Morrison, G., Dolan, M. E., & Fleming, G. F. (2016). (SICI)1097-0274(199606)29:6<602::AID-AJIM4>3.0.CO;2-L
Chemotherapy-induced peripheral neuropathy: Current status Jette, D. U., Stilphen, M., Ranganathan, V. K., Passek, S. D., Frost,
and progress. Gynecologic Oncology, 140, 176–183. https://doi. F. S., & Jette, A. M. (2014). Validity of the AM-PAC “6–Clicks”
org/10.1016/j.ygyno.2015.11.011 inpatient daily activity and basic mobility short forms. Physical
Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., Therapy, 94, 379–391. https://doi.org/10.2522/ptj.20130199
&  ­Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index Kim, J. H., Dougherty, P. M., & Abdi, S. (2015). Basic science and
(PSQI): A new instrument for psychiatric research and prac- clinical management of painful and non-painful c­ hemotherapy-​
tice. Psychiatry Research, 28, 193–213. https://doi.org/10.1016/​ related neuropathy. Gynecologic Oncology, 136, 453–459. https://
0165-1781(89)90047-4 doi.org/10.1016/j.ygyno.2015.01.524
Cavaletti, G., Frigeni, B., Lanzani, F., Platti, M., Rota, S., B­ riani, Kinesio University. (2013). KT3: Clinical concepts and advanced
C., . . . Italian NETox Group. (2007). The Total N ­ europathy taping methods. Albuquerque, NM: Kinesio Taping Association
Score as an assessment tool for grading the course of International.
­chemotherapy-induced peripheral neurotoxicity: Comparison Lee, C., & Mohammed, A. (2018, April). Therapeutic use of K-tape
with the National Cancer Institute Common Toxicity Scale. to minimize neuropathy induced functional deficits in the can­
Journal of the Peripheral Nervous System, 12, 210–215. https:// cer population. Poster presented at the American Occupational
doi.org/10.1111/j.1529-8027.2007.00141.x Therapy Association Annual Conference, Salt Lake City.
Cella, D. F., Tulsky, D. S., Gray, G., Sarafian, B., Linn, E., Bonomi, Mathiowetz, V., Weber, K., Kashman, N., & Volland, G. (1985).
A., . . . Brannon, J. (1993). The Functional Assessment of Can- Adult norms for the Nine-Hole Peg Test of finger dexterity.
cer Therapy scale: Development and validation of the general Occupational Therapy Journal of Research, 5, 24–28. https://doi.
measure. Journal of Clinical Oncology, 11, 570–579. https://doi. org/10.1177/153944928500500102
org/10.1200/JCO.1993.11.3.570 Matsuoka, H., Nakamura, K., Matsubara, Y., Ida, N., Saijo,
Chen, C., Granger, C., Peimer, C., Moy, O., & Wald, S. (2005). M., Ogawa, C., & Masuyama, H. (2018). The influence of
Manual Ability Measure (MAM-16): A preliminary report on chemotherapy-induced peripheral neuropathy on quality of
a new patient-centered and task-oriented outcome measure of life of gynecologic cancer survivors. International Journal
hand function. Journal of Hand Surgery, 30, 207–216. https:// of Gynecologic Cancer, 28, 1394–1402. https://doi.org/10.1097/
doi.org/10.1016/j.jhsb.2004.12.005 igc.0000000000001320
Davies, P. S. (2013). Chronic pain management in the cancer MD Anderson Cancer Center. (2017). Peripheral neuropathy.
­survivor: Tips for primary care providers. Nurse Practitioner, Retrieved from https://www.mdanderson.org/patient-education/
38(6), 28–38. https://doi.org/10.1097/01.NPR.0000429893.​ Endocrine/Peripheral-Neuropathy_docx_pe.pdf
95631.63 MD Anderson Cancer Center. (2018). Brief Fatigue Inventory (BFI).
Deutsch, A., Braun, S., & Granger, C. V. (1996). The Functional Retrieved from https://www.mdanderson.org/research/depart-
Independence Measure (FIM Instrument) and the Functional ments-labs-institutes/departments-divisions/symptom-research/
Independence Measure for Children (WeeFIM Instrument): symptom-assessment-tools/brief-fatigue-inventory.html
Ten years of development. Clinical Reviews in Physical and Moore, R. J., & Groninger, H. (2013). Chemotherapy-induced
Rehabilitation Medicine, 8, 267–281. peripheral neuropathy in pediatric cancer patients. Cureus,
Gewandter, J. S., Fan, L., Magnuson, A., Mustian, K., Peppone, 5(6), e124. https://doi.org/10.7759/cureus.124
L., Heckler, C., . . . Mohile, S. G. (2013). Falls and functional Ng, C., Ho, D., & Chow, S. (1999). The Moberg Pickup Test: Results
impairments in cancer survivors with chemotherapy-induced of testing with a standard protocol. Journal of Hand Therapy, 12,
peripheral neuropathy (CIPN): A University of Rochester 309–312. https://doi.org/10.1016/s0894-1130(99)80069-6
CCOP study. Supportive Care in Cancer, 21, 2059–2066. https:// Oakley, F. M., Kielhofner, G., Barris, R., & Reichler, R. (1986). The
doi.org/10.1007/s00520-013-1766-y Role Checklist: Development and empirical assessment of reli-
Gilchrist, L. (2012). Chemotherapy-induced peripheral neurop- ability. Occupational Therapy Journal of Research, 6, 158–170.
athy in pediatric cancer patients. Seminars in Pediatric Neurol­ https://doi.org/10.1177/153944928600600303
ogy, 19, 9–17. https://doi.org/10.1016/j.spen.2012.02.011

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 252 PART IV.  Sequelae of Cancer and Interventions Across the Lifespan

Park, S. B., Goldstein, D., Krishnan, A. V., Lin, C. L., Friedlander, Speck, R. M., DeMichele, A., Farrar, J. T., Hennessy, S., Mao, J. J.,
M. L., Cassidy, J., . . . Kiernan, M. C. (2013). Chemotherapy-­ Stineman, M. G., & Barg, F. K. (2012). Scope of symptoms and
induced peripheral neurotoxicity: A critical analysis. CA: self-management strategies for chemotherapy-induced periph-
A Cancer Journal for Clinicians, 63, 419–437. https://doi. eral neuropathy in breast cancer patients. Support Care Center,
org/10.3322/caac.21204 20, 2433–2439. https://doi.org/10.1007/s00520-011-1365-8
Parkinson, S., Forsyth, K., & Kielhofner, G. (2001). The Model Taillibert, S., Rhun, E. L., & Chamberlain, M. C. (2016).
of Human Occupation Screening Tool (MOHOST). Chicago: ­Chemotherapy-related neurotoxicity. Current Neurology and
Model of Human Occupation Clearinghouse, University of Neuroscience Reports, 16(9), 81. https://doi.org/10.1007/s11910​
­Illinois at Chicago. -016-0686-x
Pergolotti, M., Williams, G. R., Campbell, C., Munoz, L. A., Veale, P. (2016, August 26). Rehabilitation management for
& Muss, H. B. (2016). Occupational therapy for adults with chemo-induced peripheral neuropathy. Retrieved from http://​
­
cancer: Why it matters. Oncologist, 21, 314–319. https://doi. www.rehabpub.com/2016/08/rehabilitation-management-​
org/10.1634/theoncologist.2015-0335 chemo-​induced-peripheral-neuropathy/
Peripheral neuropathy. (n.d.). In Merriam-Webster Online. Wang, Y.-C., Bohannon, R. W., Kapellusch, J., Garg, A., &
Retrieved from https://www.merriam-webster.com/dictionary/ ­Gershon, R. C. (2015). Dexterity as measured with the 9-Hole
peripheral%20neuropathy Peg Test (9-HPT) across the age span. Journal of Hand Therapy,
Seretny, M., Currie, G. L., Sena, E. S., Ramnarine, S., Grant, R., 28, 53–60. https://doi.org/10.1016/j.jht.2014.09.002
MacLeod, M. R., . . . Fallon, M. (2014). Incidence, prevalence, Weinstein, S. (1993). Fifty years of somatosensory research.
and predictors of chemotherapy-induced peripheral neuropa- Journal of Hand Therapy, 6, 11–22. https://doi.org/10.1016/
thy: A systematic review and meta-analysis. Pain, 155, 2461– S0894-1130(12)80176-1
2470. https://doi.org/10.1016/j.pain.2014.09.020

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 Psychosocial Issues 20
Kathleen Lyons, ScD, OTR/L

LEARNING OBJECTIVES
After completing this chapter, readers should be able to
■■ Identify appropriate instruments and referral resources to use in screening for distress, anxiety, and depression in
­cancer survivors across the lifespan;
■■ Understand the potential for cancer survivors to experience posttraumatic growth and enhanced well-being after
­cancer diagnosis across the lifespan;
■■ Articulate the rationale for using occupational engagement to enhance the mental health of cancer survivors across
the lifespan; and
■■ Foster well-being of cancer survivors via occupational engagement across the lifespan.

KEY TERMS AND CONCEPTS

■■ Anxiety ■■ Distress ■■ Posttraumatic growth
■■ Avoidance behavior ■■ Distress Thermometer ■■ Posttraumatic stress
■■ Cognitive–behavioral therapy ■■ Fear of recurrence ■■ Transdiagnostic approach
■■ Depression ■■ Occupational engagement

INTRODUCTION DEFINING FEATURES OF THE

Treatment advances and rising survival rates have prompted PSYCHOSOCIAL SEQUELAE
health care practitioners to characterize cancer as a chronic ASSOCIATED WITH CANCER
illness (Phillips & Currow, 2010) as opposed to the terminal
diagnosis it was once assumed to be. Despite this, few people Posttraumatic Growth
receive a cancer diagnosis without feeling shocked and aware Posttraumatic growth refers to both a process and an
of their own mortality (Singer, 2018). Responses to this acute outcome whereby a person experiences improved adap-
awareness of mortality vary among individuals. Some peo- tation, awareness, and psychological functioning after
ple experience psychosocial challenges of distress, anxiety, or confronting an upsetting event (Tedeschi et al., 1998).
depression. Others report the phenomenon of posttraumatic Such improvements have been reported by pediatric can-
growth, which occurs when the cancer experience prompts cer survivors (Zamora et al., 2017), adult cancer survivors
increased resilience and mental health (Zamora et al., 2017). (Mehrabi et al., 2015), and parents of pediatric cancer
Additionally, people can experience both psychosocial chal- survivors (Barakat et al., 2006). Survivors of childhood
lenges and growth at points along the cancer experience (Jim cancers and adult cancer survivors have reported improve-
& Jacobsen, 2008; Schroevers et al., 2011). ments in areas such as resilience and personal strength,
This chapter explores these psychosocial issues from the spirituality, appreciation of life, social relationships, and
perspective of occupational therapy. The chapter’s central recognition of new possibilities for life choices (Tedeschi
thesis is that occupation is a powerful medium through & Calhoun, 2004; Zamora et al., 2017). Although many
which to tackle psychosocial challenges and promote psy- studies describe the features of posttraumatic growth, less
chosocial growth. Keeping our primary focus on promoting is known about when and how it develops in survivors
and enabling occupational engagement is our profession’s (Zamora et al., 2017).
unique contribution to cancer rehabilitation.

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org/10.7139/2020.978-1-56900-602-3.020

253

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