Constance Visovsky

Putting Evidence Into Practice®: Evidence-Based Interventions for Chemotherapy-Induced Peripheral Neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN) continues to be a significant, debilitating symptom resulting from the administration of neurotoxic chemotherapy for the treatment of cancer. CIPN is an important consequence of cancer treatment because of its potential impact on physical functioning and quality of life. Oncology nurses play an important role in assessing, monitoring, and educating clients about CIPN. Despite investigations concerning pharmacologic and nonpharmacologic approaches to either preventing or minimizing the neurotoxicity resulting from certain chemotherapeutic agents, evidence to support the interventions is lacking. This article presents information concerning CIPN and summarizes the evidence for pharmacologic and nonpharmacologic approaches to the prevention and treatment of CIPN.

From professional silos to interprofessional education: campuswide focus on quality of care.

Objectives The Institute of Medicine called for the integration of interprofessional education (IPE) into health professions curricula, in order to improve health care quality. In response, we developed, implemented, and evaluated a campus wide IPE program, shifting from traditional educational silos to greater collaboration. Methods Students (155) and faculty (30) from 6 academic programs (nursing, medicine, public health, allied health, dentistry, and pharmacy) engaged with a university hospital partner to deliver this program. The content addressed principles of IPE, teamwork development and 2 common quality care problems: hospital-acquired infections and communication errors. Pre-/post-surveys, the Readiness for Interprofessional Learning Scale, and the Interprofessional Education Perception Scale, were used for descriptive assessment of student learning. Results Students demonstrated increased understanding of health care quality and interprofessional teamwork principles and reported positive attitudes toward shared learning. While responses to the Readiness for Interprofessional Learning Scale grew more positive after the program, scores on the Interprofessional Education Perception Scale were more homogeneous. Both students and faculty highly evaluated the experience. Conclusion This program was a first step in preparing individuals for collaborative learning, fostering awareness and enthusiasm for IPE among students and faculty, and demonstrating the feasibility of overcoming common barriers to IPE such as schedule coordination and faculty buy-in.

Muscle Strength, Body Composition, and Physical Activity in Women Receiving Chemotherapy for Breast Cancer

There is evidence to suggest that treatment of breast cancer with chemotherapy can induce metabolic changes in skeletal muscle. Women undergoing treatment for breast cancer with certain chemotherapeutic agents can experience declines in lean body mass and muscle strength and a subsequent increase in body weight. These alterations not only can lead to declines in physical function but also predispose women to weight-related chronic illness. Excess body weight may also play a role in the development or recurrence of breast cancer. There is evidence that physical exercise may improve body composition and enhance muscular endurance, flexibility, and quality of life (QOL) in women with breast cancer. While studies of aerobic, resistance, and combinations of aerobic and resistance exercise for women with breast cancer have been conducted, most studies employed supervised aerobic exercise sessions. Few studies have examined the role of resistance exercise or the combination of resistance and aerobic exercise in maintaining or increasing muscle strength while preserving lean body mass in this population. The relatively small sample sizes and short duration of physical activity interventions in previous studies make it difficult to detect dose responses to exercise training. Physical activity interventions with larger sample sizes and of longer duration are necessary to achieve long-term health outcomes. Physical activity interventions that include the older or more obese women with breast cancer are also needed, as this population may be most at risk of functional decline and the development of chronic illness. Interventions appropriate for women treated for breast cancer who have comorbid disease are also needed. Newer, more intense chemotherapy regimens may induce a differential effect on muscle strength and body composition. However, the role of physical activity during dose-dense chemotherapy protocols has not been established.

Strength and balance training for adults with peripheral neuropathy and high risk of fall: current evidence and implications for future research

PURPOSE/OBJECTIVES To evaluate the evidence for strength- and balance-training programs in patients at high risk for falls, discuss how results of existing studies might guide clinical practice, and discuss directions for additional research. DATA SOURCES A search of PubMed and CINAHL® databases was conducted in June 2011 using the terms strength, balance training, falls, elderly, and neuropathy. Only clinical trials conducted using specific strength- or balance-training exercises that included community-dwelling adults and examined falls, fall risk, balance, and/or strength as outcome measures were included in this review. DATA SYNTHESIS One matched case-control study and two randomized, controlled studies evaluating strength and balance training in patients with diabetes-related peripheral neuropathy were identified. Eleven studies evaluating strength and balance programs in community-dwelling adults at high risk for falls were identified. CONCLUSIONS The findings from the reviewed studies provide substantial evidence to support the use of strength and balance training for older adults at risk for falls, and detail early evidence to support strength and balance training for individuals with peripheral neuropathy. IMPLICATIONS FOR NURSING The evidence demonstrates that strength and balance training is safe and effective at reducing falls and improving lower extremity strength and balance in adults aged 50 years and older at high risk for falls, including patients with diabetic peripheral neuropathy. Future studies should evaluate the effects of strength and balance training in patients with cancer, particularly individuals with chemotherapy-induced peripheral neuropathy.

Fatigue and Other Variables During Adjuvant Chemotherapy for Colon and Rectal Cancer

PURPOSE/OBJECTIVES To examine patterns of fatigue and other variables (sleep quality, sleep-wake variables, activity and rest, circadian rhythms, quality of life [QOL], blood counts, and demographic and medical variables) during colon and rectal cancer adjuvant chemotherapy, as well as feasibility of the study. DESIGN Longitudinal, descriptive feasibility study. SETTING Two oncology clinics in the midwestern region of the United States. SAMPLE From April 2006-December 2008, 27% of screened subjects (n = 21) enrolled and 14 completed the study. Participants were middle aged, partnered, and employed and had postsecondary education. METHODS Measurements completed during the first week of three two-week cycles (chemotherapy 1-3) and at six weeks (before chemotherapy 4) were the Piper Fatigue Scale, Pittsburgh Sleep Quality Index, wrist actigraphy, Functional Assessment of Cancer Therapy-Colon, blood counts, and demographic and medical data form. Analysis included descriptive statistics and repeated-measures analysis of variance. MAIN RESEARCH VARIABLES Fatigue, sleep quality, sleep-wake variables, activity-rest, circadian activity rhythms, and QOL. FINDINGS Fatigue was mild at baseline and rose to moderate levels during chemotherapy 1-3. Sleep quality was poor the months prior to chemotherapy 1 and chemotherapy 4. Actigraphy data revealed disturbed sleep, low daytime activity, and impaired circadian activity rhythms during the first week after chemotherapy 1-3. QOL ratings were similar to those in other cancer populations. Fatigue increased, and white blood cell counts decreased significantly over time. CONCLUSIONS During adjuvant chemotherapy, patients reported moderate fatigue and poor sleep quality; actigraphs confirmed problems with sleep maintenance as well as low daytime activity and disturbed circadian rhythms. Multiple barriers were encountered during the study. IMPLICATIONS FOR NURSING Clinicians should screen for fatigue and sleep-wake variables and use guidelines to select interventions.

The Symptom Experience of Patients with Cancer.

There is little doubt that despite advances in supportive cancer care, unrelieved symptoms continue to be prevalent and persistent in the cancer patient population. The purpose of this study was to describe the symptom experience of patients with cancer and pain. Secondary analysis of data gathered for a larger ongoing National Institutes of Health–funded study of medication-induced constipation was conducted to determine the following: the mean number of symptoms reported, the most commonly occurring symptoms, symptoms with the highest severity, and the symptoms causing the most distress. The sample consisted of 393 outpatients at an National Cancer Institute–designated cancer center in west-central Florida, 70% with advanced disease. The sample was predominantly female (57.7%); had either breast or lung cancer or lymphoma (53.7%); and had stage III or IV disease (51.3%). Two hundred ninety-eight of the 393 (75.8%) patients for whom data were available reported pain and were included in this analysis. Patients reported between two and 30 symptoms, each with a mean of 14.1 (SD, 5.5). As in earlier symptom studies of cancer patients, fatigue was the most commonly reported, occurring in more than 91% of the patients. The next most frequently reported symptoms were feeling drowsy (66.8%, n = 199), difficulty sleeping 65.8%, n = 196), and worrying (n = 193, 64.8%). Symptoms with the greatest severity were hair loss and impaired sexual activity, which were reported to be severe or very severe by more than 50% of the patients who had these symptoms. However, lack of energy/fatigue, pain, and difficulty sleeping were the most distressing problems and were reported to be quite a bit or very bothersome by at least 50% of patients with each symptom. Pain, fatigue, and difficulty sleeping continue to be among the most frequently reported and distressing symptoms for persons with cancer. In addition to asking about the presence of symptoms patients may be experiencing, nurses must also inquire about the associated distress. Knowing which symptoms are causing the most distress for patients will assist nurses in prioritizing their care and providing the much needed support and education for this population. Continued attention on treating these symptoms should be the focus of ongoing research as well as nursing education both in service areas and in schools of nursing.

Usual and worst symptom severity and interference with function in breast cancer survivors.

BACKGROUND Breast cancer survivors receive routine medical follow-up but are screened less frequently to detect symptom severity and interference with function in daily life. OBJECTIVES Among breast cancer survivors, we describe the usual and worst severity of 5 common symptoms and the extent to which these symptoms interfere with general activity and enjoyment of life, we determine the associations among symptoms and the interference items, and we explore associations of interference with function and the most prevalent symptoms. METHODS The cross-sectional, descriptive 1-page Breast Cancer Survivor Symptom Survey was mailed to breast cancer survivors identified in a clinical database (ONCOBASE). In total, 184/457 (40.3%) surveys were returned and 162 (35.4%) were used. Participants recorded usual and worst severity of 5 symptoms (fatigue, disturbed sleep, pain, distress, and numbness/tingling) and symptom interference with general activity and enjoyment of life during the past 7 days. RESULTS Participants reported usual symptom severity as mild and highest for sleep disturbance, followed by fatigue, distress, numbness/tingling, and pain. Participants recorded worst sleep disturbance and fatigue as moderately severe. Higher pain and fatigue were associated with all other symptoms, whereas disturbed sleep and distress were related to all except numbness/tingling. All symptoms interfered with general activity and enjoyment of life. Pain and numbness/tingling were associated with lower function and disturbed sleep, and made a unique contribution to fatigue. LIMITATIONS Limitations of the study include relatively low response and use of a modification of an established scale. CONCLUSION Symptoms often coexisted and contributed to interference with daily function. Pain was most consistently associated with interference with function and severity of other symptoms.

Evaluation and Management of Peripheral Neuropathy in Diabetic Patients With Cancer

Recently, chemotherapy-induced peripheral neuropathy has received a great deal of attention. However, the interaction of diabetic neuropathy with potentially neurotoxic chemotherapy is far less understood. The incidence of type II diabetes has risen exponentially in the past two decades. In concert with the rise in type II diabetes, the number of individuals with diabetes who need chemotherapy for cancer also is expected to increase. Diabetic neuropathy and the neurotoxic effects of chemotherapy have a significant potential to cause functional disability. Diabetics may be most at risk for the effects of neurotoxic agents on peripheral nerve functioning, in addition to the other effects induced by chemotherapeutic agents. The purpose of this article is to review the evaluation, management, and clinical implications of peripheral neuropathy in patients with cancer and diabetes.

Clinical Evaluation and Patterns of Chemotherapy‐Induced Peripheral Neuropathy

Purpose To determine the pattern of change in peripheral nerve function (as measured by vision, hearing, deep tendon reflexes, vibratory sense, cutaneous sensation, gait and balance, muscle strength, and orthostatic blood pressure) occurring among individuals receiving cancer treatment with known neurotoxic agents. Data Sources A convenience sample of 16 participants with cancer who were receiving chemotherapy had their peripheral nerve function assessed at baseline and at 4 weeks and 12 weeks of treatment. Data were analyzed using plots and regression slopes to determine change over time in clinical measures of peripheral nerve function. Outcome variables were vision, hearing, deep tendon reflexes, vibratory sense, cutaneous sensation, gait and balance, muscle strength, and changes in orthostatic blood pressure. Conclusions This is the first prospective study to use comprehensive clinical measures of peripheral nerve and muscle changes resulting from combination chemotherapy or a biotherapy regimen. Alterations in vision, hearing, deep tendon reflexes, vibratory sense, cutaneous sensation, balance, muscle strength, and orthostatic blood pressure were noted, but gait remained unchanged. Implications for Practice This study provides beginning evidence of the need for careful, ongoing assessment of treatment‐induced peripheral neuropathy. Standardized clinical practice procedures that incorporate patient evaluation for peripheral neuropathy must still be developed.In addition, we must educate our patients about the functional changes they may expect, and we must develop strategies to assist them in managing limitations that they experience as a result of peripheral neuropathy.

Chemotherapy-Induced Peripheral Neuropathy

Oncology nurses play a critical role in the assessment and management of chemotherapy-induced peripheral neuropathy (CIPN). Baseline and ongoing evaluation of physical function is a critical but often overlooked aspect of assessment of CIPN. The diversity of symptoms and the complexity associated with neuromuscular assessment lead to challenges in evaluation and management of CIPN. To meet this challenge, the authors devised a feasible algorithm to guide oncology nurses in the assessment and management of CIPN using techniques that can easily be implemented in a variety of clinical settings. Managing pain, maintaining safety, and maximizing physical function are the primary goals for nursing management of CIPN.