What does chemotherapy-induced peripheral neuropathy (CIPN) look like?
Across all ages, peripheral neuropathy causes weakness, odd sensations, and changes in motor skills such as walking, running, jumping and balance. These deficits look different for children of different ages.
- Toddlers and preschoolers may have difficulty walking and keeping up with family members as they used to. A preschooler who previously had no difficulty on stairs may have to hold on to the railing when going down or place both feet on each step. Often time, children are no longer able to jump with both feet leaving the ground. Tip-toe walking is an indicator of foot and ankle weakness due to CIPN.
- Elementary school-age children may have difficulty running and keeping up with their peers. Often, children are no longer able to hop on 1 foot or jump up to a curb. Handwriting can become difficult and harder to read as hand weakness increases. You may notice that your child’s walking pattern changes and becomes louder, an indicator of foot and ankle weakness. Frequent tripping when walking can indicate changes in balance
- Teenagers tend to experience muscular fatigue in their arms and legs. It may become difficulty to climb a long flight of stairs or keep up with peers. Teenagers previously athletic may have trouble jumping, hopping, and participating in sports. Their Achilles’ tendon can become tight, resulting in a less efficient walking pattern. Teenagers may also experience hand weakness, resulting in difficulty writing, typing, or texting.
How can I help my child?
Being aware of chemotherapy-induced peripheral neuropathy and watching for changes in your child’s motor skills are the first steps in helping minimize the impact. If you do see changes in walking, running, jumping, etc, make sure to bring them up to your Oncologist.
The therapist will plan an exercise program to increase and maintain flexibility, strength, and motor skills that your child may have difficulty with. Sometimes, the therapist may recommend weekly sessions to work on specific areas.
Physical and Occupational Therapists can speak with your child’s doctors about the motor and sensory neuropathy.
In addition to working with a therapist, you can help your child stay strong and active by encouraging physical activity. Even short burst of games and movement can help your child get stronger and feel better.
Our physical therapists have developed new and creative physical therapy interventions called The Stoplight Program for children undergoing treatment for acute lymphocytic leukemia (ALL).
Will CIPN ever go away?
When children are no longer receiving the chemotherapy that caused neuropathy, symptoms typically start to improve. However, some children do have lasting effects of CIPN. A 2012 research study found that 15% of long-term childhood cancer survivors had balance deficits.
There can be residual weakness in your child’s feet and ankles, as well as tightness in their heel cords that takes time to improve. Usually, a child is able to return to jumping, running and other activities if he/she has been working on specific strengthening activities during chemotherapy treatment. General activity alone typically will not improve the weakness or motor issues caused by CIPN, but specific exercises from a physical or occupational therapist will help significantly.
Frequently Asked Questions
When does CIPN occur in treatment?
- Children usually start to show symptoms of CIPN during the phase of treatment when they get the most vincristine. For Acute Lymphoblastic Leukemia, this is Interim Maintenance and Delayed Intensification
- CIPN can occur at any time during treatment
Will it just get better by our child being active?
- Children that stay active during treatment often remain strong. However, children often figure out ways to compensate for their weakness, resulting in atypical movement patterns
- A physical or occupational therapist is able to develop specific exercises and activities to limit compensations and help your child regain strength and balance and continue to develop new skills
Does walking on your toes really matter for later in life?
- Yes, toe-walking does impact walking for children as they get older. Children that walk on their toes have a shorter stride length, and thus have to work harder to keep up with peers when walking and running
- Toe walking can lead to muscle tightness that makes it hard to wear shoes, stand with a flat foot, squat, maintain balance, or hop on one foot
- Because of muscle tightness, children who walk on their toes are at a higher risk of ankle sprains and are more likely to have ankle and leg pain in the future
Can I expect my child to keep up with other kids?
- During chemotherapy treatment, your child may have time when it is difficult to keep up with other kids. This can be related to CIPN and subsequent muscle weakness, but also general fatigue from cancer treatment.
- When your child is no longer receiving intensive chemotherapy, he/she should be able to keep up with other kids to the same extent as before chemotherapy.
For Health Professionals
Physicians: Asking parents a few quick questions can give you insight about any symptoms of neuropathy
- Any pain or tingling in your child’s hand, feet, legs, or jaw?
- Any increase in clumsiness, tripping, or falling?
- Any trouble running or climbing stairs?
- Does your child seem to walk differently than they have previously?
- Any difficulty coloring/writing or holding crayons/pencils?
Physical Therapists: During the evaluation, make sure to look closely at the following areas, as they are most commonly involved in CIPN
- Single-leg stance and other balance measures
- Dorsiflexion and plantarflexion strength
- Great toe extension strength
- Light touch and sharp-dull sensation
- Gait: foot slap, early heel rise, shortened step length
- Stair technique
- Hopping and jumping
- Standardized gross motor assessment, as children should maintain normal gross motor skills for their age, even while being treated for cancer
Physical therapy intervention suggestions:
- Ankle strengthening
- Foot intrinsic muscle strengthening
- Balance activities
- Hopping and jumping activities
- Age-appropriate stair technique
- Grip and pinch strength
- Fine motor skills
- Decrease in motor performance in children with cancer is independent of the cumulative dose of vincristine. By Hartman A, van den Bos C, Stijnen T, Pieters R.
- Early-phase adaptations to intrahospital training in strength and functional mobility of children with leukemia. By San Juan AF, et al.
- Neuromuscular impairments in adult survivors of childhood acute lymphoblastic leukemia: associations with physical performance and chemotherapy doses. By Ness KK et al.
- Gilchrist, L. S., L. Marais, and L. Tanner. Comparison of two chemotherapy-induced peripheral neuropathy measurement approaches in children. Supportive Care in Cancer 22.2 (2014): 359-366.
- Gilchrist, LS., and Tanner L. The pediatric-modified total neuropathy score: A reliable and valid measure of chemotherapy-induced peripheral neuropathy in children with non-CNS cancers.” Supportive Care in Cancer 21.3 (2013): 847-856.