September 7, 2018

Neuropathy with Dr. Michael Stubblefield:

Highlights from the Neuropathy & Cancer AppChat Sponsored by Seattle Genetics and ReVital Cancer Rehabilitation


Missed the Neuropathy & Cancer AppChat with cancer rehabilitation expert Dr. Stubblefield? Attended and want a recap? No worries, we’ve got you covered! Read below to find out what information Dr. Stubblefield shared during the AppChat as well as what questions he answered from those in attendance. You’ll also find more information on Dr. Stubblefield, resources and our sponsors!


Part I: Neuropathy & its Signs/Symptoms

Information from Dr. Stubblefield:

The central nervous system (CNS) consists of the brain and spinal cord. The peripheral nervous system (PNS) consists of everything outside of the brain and spinal cord. Nerve roots come out of the spinal cord, literally resembling the roots of a tree, join into complex interconnections called plexuses, and then branch into large-named nerves, such as the sciatic nerve, which travel to the rest of the body.

There are motor nerves which supply impulses to the muscles, sensory nerves which relay sensation from the body, and autonomic nerves which control things like blood pressure and digestion.

When we talk about peripheral neuropathy (PN) we are talking about damage to the nervous system outside of the brain and spinal cord.

There are three major types of neuropathy problems:

Sensory problems: This is usually pain or the loss of the ability to feel. Sometimes it presents as numbness and/or tingling, which we call paresthesia.

Motor problems: This is the loss of the ability to work the muscle, which presents as weakness. It usually occurs distally out in the hands or out in the feet.

Autonomic problems: The autonomic nervous system, which is part of the PNS, controls bodily functions such as digestion, heart rate, blood pressure, and sexual arousal. These functions may be altered by damage to the PNS.

Different causes of neuropathy will affect the different parts of the PNS differently. For example, platinum drugs primarily damage sensory nerves. You may have pain and lose the ability to know where your joints are in space, but your muscles still remain strong. Severity of neuropathy can also vary widely. Neuropathy could just be numbness in your fingers or, in extreme cases, it can cause paralysis.

Q&A with Dr. Stubblefield:

Q: Can neuropathy affect the face?
A: Neuropathy of the face does happen, but it’s rare. It’s usually a vasculitic phenomenon.

Q: Are muscle fasciculations a form of neuropathy? 
A: Muscle fasciculations, or muscle twitching, can be caused by neuropathy. Motor nerves can send false signals to the muscle, which spasms in response.

Q: Can neuropathy cause erectile dysfunction (ED)? 
A: It absolutely can. It can occur from damage to the autonomic nervous system. It’s relatively rare though and the neuropathy is usually significant elsewhere. If it is only ED, then we would look for other causes.

Q: Can neuropathy cause toe cramps? 
A: It absolutely can. If the motor nerves are damaged and send false signals to the muscles of the toe.

Q: My neuropathy pain is much worse in the cold. What causes neuropathy pain to worsen in the cold? 
A: It is very common for neuropathy to become more painful in the cold. The cold makes the nerves fire differently, causing more pain.

Q: Is it common to have no symptoms of neuropathy during chemotherapy, but have it develop after chemotherapy has ended? 
A: Yes, it is common with agents such as the platinum drugs and is known as “coasting”.

Part II: Causes of Neuropathy

Information from Dr. Stubblefield:

In the world, the most common cause of neuropathy is leprosy. In the United States, the most common cause of neuropathy is diabetes. While in cancer, the most common cause is chemotherapy — particularly the vinca alkaloids, the taxanes and the platinum drugs.

Different chemotherapies can cause different types of neuropathy.

For example:

The vinca alkaloids and taxanes are what we call tubulin inhibitors. Tubulin is a type of protein that acts similarly to a pulley system. Among other things, cells use tubulin to divide. Tubulin inhibitors disrupt the process of cell division and cause the cell to die. If it is a cancer cell, this is a good thing. If it is a normal cell, this can lead to unwanted side effects. Tubulin inhibitors affect both sensory and motor nerves equally. Platinum drugs target the DNA of the cell and cause changes in normal cell functions, such as the ability to repair DNA and/or create new DNA. They only affect sensory nerves and not the motor nerves. To the trained eye, tubulin inhibitors and platinum drugs result in very different types of neuropathy.

A number of things can mimic chemotherapy-induced PN. Both a pinched nerve, which may be caused by bad arthritis or a disk herniation in the back, and carpal tunnel syndrome can cause numbness and tingling. These effects can be easily mistaken for PN.

More than one factor can contribute to neuropathy. A good neuromuscular medicine clinician should be able to sort out the cause or causes of the neuropathy.

Q&A with Dr. Stubblefield:

Q: Does chemotherapy-induced PN develop immediately or over time?
A: It depends on the chemotherapeutic agent. Neuropathy is an immediate side effect of the vinca alkaloids and taxanes, but it usually gets better once you’ve stopped the chemotherapy. Platinum drugs affect the DNA, which means neuropathy is more likely to develop over time and may continue to get worse 6 to 9 months after you’ve stopped chemotherapy. This is referred to as the coasting effect.

Q: How common is neuropathy in patients that have been treated with platinum drugs?
A: It depends on the dose. Most patients will get some neuropathy, but it typically goes away for a significant percentage of them.

Q: Why are some people more susceptible to chemotherapy-induced PN?A: A person may be more susceptible to chemotherapy-induced PN if there is a pre-existing issue, such as diabetes, or even a pinched nerve somewhere. This can make the nerves more sensitive to chemotherapy. Sometimes there is no identifiable reason.

Q: What about radiation? What kind of neuropathy is most typical following radiation? Is it more immediate or can it be delayed?
A: Big and good question. It depends. Radiation does not cause a PN. It only damages the nerves that are inside the radiation field.

Part III: Evaluation of Neuropathy

Information from Dr. Stubblefield:

Diagnosing neuropathy can be very simple or one of the most complicated things in medicine. When a patient without any evidence of neuropathy before chemotherapy develops typical signs and symptoms of neuropathy in the treatment setting, we assume it is chemotherapy-induced PN and we don’t do any additional investigation.

When someone develops neuropathy that is not typical, then we will investigate using a detailed history and specialized physical examination. If that doesn’t get to the bottom of things, we consider nerve testing (nerve conduction studies and electromyography (EMG)), specialized laboratory studies, and sometimes imaging.

There are many nerve issues that might not have caused issues before treatment that can come out as a result of it. Much of the testing is to ensure that isn’t another type of neuropathy (vitamin B12 deficiency, diabetes, Lyme disease, etc.) or a mimic of neuropathy, such as spinal stenosis (narrowing) which compresses the nerves coming out of the spine.

Q&A with Dr. Stubblefield:

Q: Where do I find a neuromuscular medicine clinician? What qualifications should I be looking for?
A: Most neurologists have at least some training. Those with a board certification in electrodiagnostic medicine, such as EMG, are even better. Rehabilitation physicians are also experts in neuromuscular medicine.

Part IV: Treatment of Neuropathy

Information from Dr. Stubblefield:

Numbness: Unfortunately, nothing really works for numbness caused by neuropathy. Feeling is lost because the nerve is not functioning or is dead.

Pain: Pain is different. In pain, the nerve is not dead, but it is sending false signals into the spinal cord and brain which are perceived as pain.

Very often those with pain respond well to medication. One of the best studied drugs for chemotherapy-induced PN pain is duloxetine (Cymbalta). Gabapentin (Neurontin) and pregabalin (Lyrica) have a different mechanism of action than duloxetine but, from my experience, can also be very effective for pain. Tricyclic antidepressants (such as, nortriptyline and amitriptyline) may also be very helpful. If non-opioid options are exhausted, sometimes we have to try opioid-type medications for pain management. These are usually effective.

Some patients use topical medication for the pain, such as lidocaine patches or topical creams compounded by pharmacists. They are not really absorbed and as a result don’t get into the CNS, but some patients swear by them.

Supplements are generally not going to make you better, unless you have a specific nutritional deficiency. Many National Cancer Institute studies have looked at various supplements in the treatment of chemotherapy-induced PN, but unfortunately none have been positive.

A vitamin B12 deficiency can cause neuropathy. Vitamin B12 is a common supplement people get for neuropathy and, if you are vitamin B12 deficient it can be curative, but for chemotherapy-induced PN it’s not.

Alternative treatments for pain management exist too, such as acupuncture, exercise and neuromodulation or scrambler therapy. My personal sense is that acupuncture is most likely to work when you believe it will work. In scrambler therapy electrical impulses on the skin are sent to overwhelm pain signals with non-pain signals.

Problems with Day-to-Day Activities: Therapy can help improve balance, coordination, dexterity and strength issues caused by neuropathy. Physical therapists can help with balance and walking (gait) issues — making patients more mobile and less likely to fall. Occupational therapists can help with strength and dexterity. They can also give you tricks to make everyday tasks easier. Therapy is not necessarily a cure, but almost everyone can become more functional and more comfortable.

Q&A with Dr. Stubblefield:

Q: What is more common in patients with chemotherapy-induced PN: numbness, pain, or both equally?
A: Both numbness and pain are very common. Numbness is a little more common. Pain is easier to treat.

Q: Is there one drug that works better for pain than others?
A: Not necessarily. Just because you don’t respond well to one drug, doesn’t mean that you won’t respond well to another drug. The drugs used to treat pain do not all act at the same target. Also, we’re all wired a little differently and, therefore, respond differently.

Q: Would cannabis or cannabidiol (CBD) oil help neuropathy symptoms?
A: There is very little high-quality data yet. I hope that once we get better clinical trials we are able to gain a better idea of whether or not it is effective.

Q: Would someone that had slightly low vitamin B12 levels before chemotherapy be more susceptible to neuropathy?
A: Yes, and it would be worth replacing the vitamin B12.

Q: Is there any negative effect of taking vitamin B12?
A: No, not at all.

Q: For problems with the autonomic nervous system, can you only treat the neuropathy symptoms or can more be done?
A: It is supportive treatment. There is no specific treatment to make the nerves work better.

Q: Any other non-pharmacological tips for dealing with neuropathy?
A: Keeping the skin in good condition with lotion can help. Avoiding constricting garments, such as socks, can also be helpful.

Q: What, if anything, can be done to prevent neuropathy if you had treatment and no neuropathy so far? Any measures that should be taken to avoid late effects in general?
A: Unfortunately, there is no treatment to prevent late effects. The treatments currently available optimize your function and control symptoms if they develop.

Q: What’s on the horizon? Do any new treatments look promising?
A: There are new medications in development to help with pain, but nothing curative as yet.


For more information on Dr. Michael D. Stubblefield.

For more information on chemotherapy-induced PN, check out Dr. Stubblefield’s recommended links:

Overview of chemotherapy-induced PN.

Understanding chemotherapy-induced PN.

Symptoms of chemotherapy-induced PN.




More on our sponsors:

Seattle Genetics

ReVital Cancer Rehabilitation


What is an AppChat?

An AppChat is a LIVE event that takes place on the Stupid Cancer App. You’ll find input and engagement from the community, along with expertise from speakers. AppChats are not only a great learning opportunity, but a way to connect with other users like yourself. Always free, check out GRYT Health on Facebook and Instagram for AppChat announcements. Questions? Contact aerial@grythealth.com.


Like what you’re reading? Follow GRYT Health on Facebook, Instagram, & Twitter for more inspiring news and stories!


Disclaimer: All content is for informational purposes only. Content is not intended as a substitute for medical advice or treatment. Consult your medical professional for any questions concerning your health.

August 22, 2018

GRYT Health presents: Neuropathy & Cancer AppChat

A GRYT Health AppChat collaboration with Seattle Genetics and ReVital Cancer Rehabilitation.

Hosted by Dr. Michael D. Stubblefield, be part of the conversation on Thursday, August 30th, from 8–9pm ET. Participate LIVE on the Stupid Cancer App, which is available to download for free, in both the Google Play and App Store.


About our host, Dr. Michael D. Stubblefield

Dr. Michael D. Stubblefield is the former Chief of Cancer Rehabilitation at Memorial Sloan-Kettering Cancer Center.

He now serves as Medical Director of Cancer Rehabilitation at Kessler Institute for Rehabilitation, and National Medical Director for Select Medical’s ReVital Cancer Rehabilitation Program. He is board certified in Physical Medicine and Rehabilitation, Internal Medicine, and Electrodiagnostic Medicine. His primary clinical expertise is in the identification, evaluation, and rehabilitation of neuromuscular, musculoskeletal, pain, and functional disorders resulting from cancer and its treatment, particularly those caused by radiation and neurotoxic chemotherapy.

Dr. Stubblefield is an accomplished researcher who has published extensively, not only in the rehabilitation literature, but in oncology, pain management, palliative care, neurophysiology, and other journals. He has authored numerous review articles and book chapters in the field of cancer rehabilitation and is the editor of Cancer Rehabilitation: Principles and Practice, the only comprehensive textbook in this emerging field.

Dr. Stubblefield has served on the Board of the American Association of Neuromuscular and Electrodiagnostic Medicine and as Chair of the Medical Council of the American Association of Physical Medicine and Rehabilitation. He is on the editorial board of the journal Muscle and Nerve. Dr. Stubblefield is a fierce advocate for the development of cancer rehabilitation and survivorship programs and champions their role in restoring function and quality of life to cancer patients.

Outside his work as a physician, Dr. Stubblefield is an accomplished wildlife
photographer, particularly of birds. He travels the world photographing some of the most rare and elusive species. His images have been published thousands of times in most every media form. You can view some of these on his website.

Publications by Dr. Stubblefield:

Publications on Pubmed

Cancer Rehabilitation 2E: Principles and Practice

Excited to be part of the discussion?

This is what we’ll be chatting about (and much more!) with our leading expert in neuropathy, Dr. Michael D. Stubblefield!

•What is neuropathy and what are the signs and symptoms of it?

•What causes neuropathy?

•How is neuropathy diagnosed?

•How is neuropathy treated?



A GRYT Health AppChat collaboration with Seattle Genetics and ReVital Cancer Rehabilitation

More on our sponsors:

Seattle Genetics

ReVital Cancer Rehabilitation

What is an AppChat?

An AppChat is a LIVE event that takes place on the Stupid Cancer App. You’ll find input and engagement from the community, along with expertise from speakers. AppChats are not only a great learning opportunity, but a way to connect with other users like yourself. Always free, check out GRYT Health on Facebook and Instagram for AppChat announcements. Questions? Contact aerial@grythealth.com.


Like what you’re reading? Follow GRYT Health on Facebook, Instagram, & Twitter for more inspiring news and stories!

August 6, 2018

GRYT Health presents: Neuropathy & Cancer

An AppChat collaboration with Seattle Genetics and ReVital Cancer Rehabilitation


Hosted by Dr. Michael D. Stubblefield, be part of the conversation on Thursday, August 30th, from 8–9pm ET. Participate LIVE on the Stupid Cancer App, which is available to download for free, in both the Google Play and App Store.

Did you know?

Some stats on neuropathy:

•Pain in cancer survivors is a common problem and can negatively affect quality of life, mental health, social interactions and employment prospects.¹,²

•More than 100 types of neuropathy have been identified. Each type has its own prognosis, symptoms and pattern of progression.³

•A 2014 meta-analysis study, which included data from 4179 patients, found that the prevalence of chemotherapy-induced peripheral neuropathy was:

  • 68% in the first month following chemotherapy.
  • 60% three months following chemotherapy.
  • 30% six months or more following chemotherapy.⁴

•Chronic severe pain that interferes with functioning affects approximately 5– 10% of cancer survivors.²

Excited to be part of the discussion?

This is what we’ll be chatting about (and much more!) with our leading expert in neuropathy, Dr. Michael D. Stubblefield!

•What is neuropathy and what are the signs and symptoms of it?

•What causes neuropathy?

•How is neuropathy diagnosed?

•How is neuropathy treated?



Behind the Seattle Genetics Neuropathy AppChat Collaboration:

GRYT Health partnered with Seattle Genetics on a Hodgkin Lymphoma (HL) project this past spring. For this project, sixty members of the HL community shared their cancer experience. Seattle Genetics was deeply touched by the candor and transparency of their stories. So much so, they wanted to both thank and support the community that participated in their project. Hearing the need of the community (unprompted, many members of the HL community mentioned their struggle with peripheral neuropathy) and as part of the celebration leading up to September being blood cancer month, the idea for an AppChat on neuropathy was created. Thank you to those who inspired this event! We truly hope that this will be beneficial to not only the HL community, but also to the broader cancer community as well.

Publications by Dr. Stubblefield:

Publications on Pubmed

Cancer Rehabilitation 2E: Principles and Practice

Sources:

¹Brown MR, Ramirez JD, Farquhar-Smith P. Pain in cancer survivors. Br J Pain. 2014 Nov;8(4):139–53.

²Glare PA, Davies PS, Finlay E, Gulati A, Lemanne D, Moryl N, Oeffinger KC, Paice JA, Stubblefield MD and Syrjala KL. Pain in cancer survivors. J Clin Oncol. 2014 Jun; 32(16):1739–47.

³Stubblefield MD, Burstein HJ, Burton AW, Custodio CM, Deng GE, Ho M, Junck L, Morris GS, Paice JA, Tummala S and Von Roenn JH. NCCN task force reports: management of neuropathy in cancer. J Natl Compr Canc Netw. 2009 Sep;7 Suppl 5:S1–26.

⁴Seretny M, Currie GL, Sena ES, Ramnarine S, Grant R, MacLeod MR, Colvin LA and Fallon M. Incidence, prevalence, and predictors of chemotherapy-induced peripheral neuropathy: A systematic review and meta-analysis. Pain. 2014 Dec;155(12):2461–70.

More on our sponsors:

Seattle Genetics

ReVital Cancer Rehabilitation

What is an AppChat?

An AppChat is a LIVE event that takes place on the Stupid Cancer App. You’ll find input and engagement from the community, along with expertise from speakers. AppChats are not only a great learning opportunity, but a way to connect with other users like yourself. Always free, check out GRYT Health on Facebook and Instagram for AppChat announcements. Questions? Contact aerial@grythealth.com.

July 26, 2018

So, What Now?

Post Anxiety and Depression AppChat Support Resources from The Progressive Institute


SUPPORT RESOURCES

Are you interested in finding a mental health therapist?

Try one of these websites:

Are you in need of crisis support?

Contact the National Suicide Hotline at 1–800–799–7233

or

text the Crisis Text Line at 741–741.

Are you looking for general information?

Contact the Anxiety and Depression Association of America (ADAA) at 240–485–1001.

Are you interested in taking an online screening for depression?

Head over to the National Cancer Institute’s website at

OR

call them at 1–800–4-Cancer.

You can also contact the GRYT team, at aerial@grythealth.com if you have any questions.

July 23, 2018

GRYT Health Presents: Managing Anxiety and Depression Through Cancer with Progressive Diagnostics…


Thursday, July 26th, from 8–9pm ET, GRYT Health will be partnering with Progressive Diagnostics, as we discuss managing anxiety and depression during/after a cancer diagnosis.

Read these five quick statistics on the impact of cancer, mental health and persons affected by cancer. Then be a part of the conversation with licensed clinical psychologist, Kate and her colleague, Greg.

•25% of cancer survivors experience symptoms of depression and up to 45% experience anxiety.¹

•Many also experience symptoms meeting the criteria of Post-Traumatic Stress Disorder (PTSD).²

•Cancer survivors who are depressed are twice as likely to die prematurely as those who are not depressed.³

•Psychological stress can promote a tumor’s growth and cause cancer to metastasize to other areas of the body.⁴

•Between a 3-year period (2010–13), 2.5 million cancer survivors nationwide (US) had used antidepressants. This equates to nearly 1 in 5 survivors taking medication for depression or anxiety years later.⁵

Meet the team from Progressive Diagnostics who will be leading this discussion:

Greg , the Director of Operations and Mental Health Initiatives at The Progressive Institute


“I have a master’s degree in psychology and have worked in various leading treatment settings in the Northeast, focusing my efforts on understanding and treating anxiety, depression and addiction. I am currently applying this understanding towards studying and developing a program aimed at preserving mental health and wellness in the cancer community. My wife and I are originally from Philadelphia, PA and moved to Connecticut to peruse our passions — teaching special education being hers and revolutionizing the mental health field being mine.

I find inspiration in the strength people discover within themselves when overcoming life’s challenges.”

Kate, the Clinical Director at The Progressive Institute


“I have a master’s degree in clinical therapy, with 20+ years’ experience in not for profit and community-based agencies, private practice, and mental health advocacy and prevention groups.I’ve come to understand that the cancer population stands to gain the most from proper mental health care, but that traditional cancer diagnosis and treatment fail the cancer community by not recognizing this need.

I believe we have the knowledge, determinations, and capability to change this paradigm by treating the whole person and not just the physical manifestations of the cancer.

I reside with my loving family in Connecticut and am enriched every day by my experiences with clients and their families.”

Progressive Diagnostics is currently in a research and development phase and will be hosting a series of these events throughout the remainder of the year. If anyone is interested in being included in future announcements and/or beta emails, please let us know by filling this form out.

Join the conversation by downloading the Stupid Cancer App (available for both iOS and Android) and entering the AppChat Discussion Chatroom. We’ll see you on the app, Thursday, July 26th, 8–9pm ET!

¹ National Cancer Institute, via Psychology Today article (https://www.psychologytoday.com/us/blog/nurturing-self-compassion/201702/neglecting-mental-health-in-cancer-treatment-0)

²National Cancer Institute, via Psychology Today article (https://www.psychologytoday.com/us/blog/nurturing-self-compassion/201702/neglecting-mental-health-in-cancer-treatment-0)

³Journal of the National Cancer Institute, https://academic.oup.com/jnci/article/106/1/djt446/2518142

National Cancer Institute (https://www.cancer.gov/about-cancer/coping/feelings/stress-fact-sheet)

Journal of Clinical Oncology, http://ascopubs.org/doi/full/10.1200/JCO.2016.67.7690