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Recognizing and Evaluating Peripheral Neuropathy in Patients With Multiple Myeloma

Sam Savary, RN, BSN, MBA, Celgene Clinical Nurse Consultant, discusses the impact and risk of peripheral neuropathy on patients with multiple myeloma.

Tip Sheet about this topic

Hello, I’m Sam Savary. Welcome to the Multiple Myeloma Center for Nurses video: Recognizing and Evaluating Peripheral Neuropathy in Patients With Multiple Myeloma.

This video is designed to help you understand some of the risk factors for peripheral neuropathy that can occur in multiple myeloma. We’ll also look at ways to evaluate the symptoms of peripheral neuropathy and their impact on patients in your practice.

Peripheral neuropathy is a condition that develops as a result of damage to the peripheral nervous system.1 The peripheral nervous system is composed of motor, sensory, and autonomic nerves.2,3 Motor nerves transmit information from the brain to voluntary muscles such as the arms and legs and play a role in the control of movement.1,4 Sensory nerves transmit information to the brain about touch, temperature, vibration, and body position.4 Autonomic nerves regulate internal body processes that require no conscious effort, such as blood pressure, heart rate, breathing, and temperature.3,5

Symptoms of peripheral neuropathy vary depending on the types of nerves involved and the extent of damage to the nerve.1 For example, muscle weakness is a common symptom of motor nerve damage while touch and light sensitivity commonly occur with sensory nerve damage.1,6

Symptoms can develop over different lengths of time, which are used to broadly classify neuropathy as acute, subacute, or chronic.7 Symptoms of acute neuropathy typically develop in less than 4 weeks, while subacute symptoms manifest in 1 to 3 months. Chronic neuropathy is characterized by symptoms that take longer than 3 months to develop.7

In the acute forms of neuropathy, symptoms appear suddenly, progress rapidly, and resolve slowly as damaged nerves heal. In chronic forms, symptoms begin subtly and progress slowly. Many will worsen over time, although some people may have periods of relief followed by relapse. Other people may reach a plateau, where symptoms stay the same for many months or years.6

Clinical presentation can also depend on the part of the nerve that is damaged (the axon or the myelin sheath).6 The axon is the conducting fiber that carries signals to and from the nerve.8 Primary axonal neuropathy is the most common type of polyneuropathies.8 Symptoms typically progress slowly and proximally, usually to the feet and lower extremities. Weakness and atrophy can occur.8

Neuropathy of the myelin sheath is called demyelinating neuropathy. The myelin sheath is an insulating fatty layer around the axon that helps speed transmission of nerve signals.8,9 Demyelinating neuropathy is less common than axonal neuropathy. It usually involves distal numbness and tingling and symptoms can also occur in the proximal portions of the limbs. Patients may also report weakness.8,9

It is not fully understood how neuropathy develops in newly diagnosed multiple myeloma.1 It may be related to paraprotein, weight loss, metabolic factors, or toxic factors associated with the malignancy. In some cases the M-protein plays a definite pathogenetic role.1,10

The clinical manifestation of peripheral neuropathy is uncommon when patients are first diagnosed.1 It affects between 1% and 20% of untreated patients.11 However, it may be a common side effect of some antimyeloma therapies, affecting between 37% and 83% of all patients receiving treatment.11 In fact, peripheral neuropathy is one of the most challenging side effects associated with certain antimyeloma therapy.1 Peripheral neuropathy can also be the result of comorbidities such as diabetes or HIV infection.6

Peripheral neuropathy in patients with multiple myeloma is usually axonal mixed sensorimotor with symmetrical, distal, and progressive symptoms. Common symptoms include numbness, tingling, sensitivity to touch, muscle weakness, or a burning sensation. Neuropathic pain is also common and can significantly impact a patient’s activities of daily living and instrumental activities of daily living, specifically putting some patients at risk for falls.1,6

The severity of neuropathy, including adverse events related to neuropathic pain, can be quantified with the National Cancer Institute’s Common Terminology Criteria for Adverse Events (or CTCAE) grading system. The grades may be used for monitoring neuropathy and determining the need and type of appropriate intervention.12

Under the CTCAE version 4.03 category of nervous system disorders, peripheral motor and sensory neuropathies are graded as follows: 1 is asymptomatic; 2 is moderate symptoms limiting instrumental activities of daily living; 3 is severe symptoms that limit self-care activities of daily living; 4 is life-threatening consequences that require urgent intervention; and 5 is death.12

Peripheral neuropathy’s physical, psychological, and social impact on the patient underscores the importance of your role in managing the condition and the impact it may have on your patients.1

Because some patients may have diabetes, establish a baseline assessment. It is important to look for and address peripheral neuropathy in a timely manner. Patients should be evaluated for signs and symptoms of peripheral neuropathy, including checking their feet, at every visit and throughout their treatment cycle.1,6

All patients should be counseled about peripheral neuropathy and evaluated regularly for signs and symptoms. Be sure to include a neurologic assessment using a neurotoxicity assessment tool at baseline, at the onset of worsening neuropathy, and at each encounter when clinically indicated. The tool shown here asks patients to rate the frequency with which they have experienced symptoms of neuropathy in the last week.1

It may also be helpful to evaluate your patients’ abilities to perform activities of daily living such as dressing and feeding themselves. Also, consider instrumental activities of daily living, secondary activities related to independent living, and safety issues at home such as avoiding injuries, falls, and burns.1

You should use adult verbal or nonverbal pain scales in your assessments and follow pain management guidelines such as those in the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for adult cancer pain.1,13 An interdisciplinary management approach may be helpful in the management of peripheral neuropathy and associated pain. Referrals to neurology, pain management, physical therapy, and psychosocial services may be warranted depending on the severity and impact on the patient.1

This concludes the Multiple Myeloma Center for Nurses video: Recognizing and Evaluating Peripheral Neuropathy in Patients With Multiple Myeloma. To find out more on this and other topics related to multiple myeloma, please see additional videos and resources on this site. Here you will find a number of educational tools including tip sheets to help you discuss these topics with your patients, answers to common questions, and other downloadable materials.

Thank you.

References:

  1. Tariman JD, Love G, McCullagh E, Sandifer S; IMF Nurse Leadership Board. Peripheral neuropathy associated with novel therapies in patients with multiple myeloma: consensus statement of the IMF Nurse Leadership Board. Clin J Oncol Nurs. 2008;12(3 Suppl):29-35.
  2. Levin M. Introduction to symptoms and diagnosis of brain, spinal cord, and nerve disorders. Merck Manuals Consumer Version. Kenilworth, NJ: Merck, Sharp & Dohme; 2015. http://www.merckmanuals.com/home/brain,-spinal-cord,-and-nerve-disorders/symptoms-and-diagnosis-of-brain,-spinal-cord,-and-nerve-disorders/introduction-to-symptoms-and-diagnosis-of-brain,-spinal-cord,-and-nerve-disorders. Accessed on February 25, 2016.
  3. Goldman SA. Nerves. The Merck Manuals Consumer Version. Kenilworth, NJ: Merck, Sharp & Dohme; 2015. http://www.merckmanuals.com/home/brain,-spinal-cord,-and-nerve-disorders/biology-of-the-nervous-system/nerves. Accessed February 25, 2016.
  4. Rubin M. Overview of the peripheral nervous system. Merck Manuals Consumer Version. Kenilworth, NJ: Merck, Sharp & Dohme; 2015. http://www.merckmanuals.com/home/brain-spinal-cord-and-nerve-disorders/peripheral-nerve-disorders/overview-of-the-peripheral-nervous-system. Accessed February 25, 2016.
  5. Low P. Overview of the autonomic nervous system. Merck Manuals Consumer Version. Kenilworth, NJ: Merck, Sharp & Dohme; 2015. http://www.merckmanuals.com/home/brain,-spinal-cord,-and-nerve-disorders/autonomic-nervous-system-disorders/overview-of-the-autonomic-nervous-system. Accessed February 25, 2016.
  6. National Institute of Neurological Disorders and Stroke. Peripheral Neuropathy Fact Sheet. http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.htm. Accessed February 25, 2016.
  7. Willison JH, Winer JB. Clinical evaluation and investigation of neuropathy. J Neurol Neurosurg Psychiatry. 2003;74(Suppl II):ii3-ii8.
  8. Bromberg MB. An electrodiagnostic approach to the evaluation of peripheral neuropathies. Phys Med Rehabil Clin N Am. 2013;24:153-168.
  9. Genetics Home Reference. Myelin Sheath. http://ghr.nlm.nih.gov/glossary=myelinsheath. Accessed February 24, 2016.
  10. Bladé J, Rosinol L. Complications of multiple myeloma. Hematol Oncol Clin North Am. 2007;21:1231‐1246.
  11. Richardson PG, Laubach JP, Schlossman RL, Mitsiades C, Anderson K. Complications of multiple myeloma therapy, part 1: risk reduction and management of peripheral neuropathy and asthenia. J Natl Compr Canc Netw. 2010;8(Suppl 1):S4‐S12.
  12. National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) (v4.0). Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; (v4.03: June 14, 2010). NIH Publication no. 09-5410.
  13. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Adult Cancer Pain. v1.2016. http://www.nccn.org. Accessed February 25, 2016.