Chemotherapy-Induced Peripheral Neuropathy

What is Chemotherapy-Induced Neuropathy?

Chemotherapy-induced peripheral neuropathy (CIPN) is damage to the nerves outside the brain and spinal cord caused by certain cancer drugs. It is a common side effect that can limit how much chemotherapy a person can receive.^[1] For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Common symptoms

CIPN is usually sensory: numbness, tingling, burning or shooting pain, often starting in the toes and fingers.^[1] Some people also have trouble with balance, buttoning clothes or feeling temperature, and for some survivors it lasts long after treatment ends.^[1]

• Numbness or "pins and needles" in the hands and feet
• Burning, shooting or electric pain
• Unsteady walking or dropping things
• Sensitivity to cold^[1]

Causes and risk factors

Several types of chemotherapy can damage peripheral nerves, including taxane and platinum drugs, and about 30 to 40 percent of people treated with neurotoxic chemotherapy develop CIPN. Severity varies widely from person to person.^[1]

How it is diagnosed and treated conventionally

Your oncology team diagnoses CIPN from your symptoms and a neurological examination, and checks that the numbness is not due to another cause. If neuropathy becomes intolerable or limits function, the guideline advises clinicians to consider delaying, reducing, substituting or stopping chemotherapy.^[2]

No agent is recommended to prevent CIPN. For established painful CIPN, duloxetine is the only drug with enough evidence to support its use, and its benefit is limited.^[2] A later meta-analysis of 7 trials found duloxetine statistically similar to placebo and called for better trials.^[3]

Why Chemotherapy-Induced Neuropathy calls for a whole-person approach

CIPN is a nerve injury, but it affects walking, sleep, work and mood, so supportive care often addresses more than the nerves. Because drug treatment offers limited benefit, many people look to non-drug approaches, and clinical guidelines have reviewed exercise and integrative options.^{[2, 4]}

Complementary care here is aimed at symptoms and daily function, and it is added to your oncology care.

Drug-related nerve injury

Chemotherapy drugs injure sensory nerves in different ways depending on the agent, and there is no proven way to prevent this damage.^{[1, 2]}

Pain and sensory symptoms

The symptoms are mostly sensory, with pain, numbness and tingling, and these can persist after chemotherapy ends.^[1]

Strength, balance and activity

Exercise may help. A meta-analysis of 16 trials found that exercise improved neuropathic pain, balance, muscle strength and quality of life in people with CIPN, though it did not clearly improve neuropathy symptoms.^[5]

Quality of life and well-being

Neuropathy can lower quality of life, and some acupuncture trials measure it. A pooled analysis of 5 sham-controlled trials found acupuncture improved quality of life more than placebo acupuncture.^[6]

Acupuncture for Chemotherapy-Induced Neuropathy

What the research shows

The research suggests acupuncture may ease CIPN symptoms, but the results are mixed and many studies are small. A network meta-analysis of 33 trials (2,027 participants) found acupuncture-related treatments better than usual care, medication or supplements for symptoms, pain and quality of life.^[7] A review of 9 trials, with a pooled analysis of 4 of them, found acupuncture may be better than vitamin B for sensory neuropathy, and called for higher-quality studies.^[8]

The picture is less clear against sham treatment. A meta-analysis of 5 sham-controlled trials found no significant difference in neurotoxicity scores, but found that acupuncture reduced pain severity and pain interference and improved quality of life more than sham.^[6] An overview of 51 reviews of acupuncture in cancer rated most as low in quality and called the evidence on neuropathy limited and inconsistent.^[9]

Individual trials add detail. A pilot trial of 60 patients receiving oxaliplatin found that electroacupuncture eased neuropathy severity more than sham acupuncture during chemotherapy, but vibration and light-touch tests did not differ.^[10] In another trial in cancer survivors, real and sham acupuncture both improved some sensory measures compared with usual care, with no difference between them.^[11] In a German crossover trial of 60 patients, acupuncture compared with a waiting period improved nerve conduction measures and symptoms, though the control group received no treatment.^[12]

How acupuncture may work

How acupuncture might help CIPN is not established. The German trial suggested it might support nerve regeneration, since nerve conduction measures improved, but that is a hypothesis from one study.^[12] In another trial real and sham needling gave similar results, so effects of the needling itself were not shown.^[11]

What treatment involves

Treatment uses fine, sterile, single-use needles, often with the needles placed on the hands, feet and legs, usually left in place for about 20 to 40 minutes. A course is several visits with reassessment. Trials gave weekly to twice-weekly sessions over several weeks, for example 10 weeks of treatment in the German trial and weekly electroacupuncture over 12 weeks in the oxaliplatin trial.^{[10, 12]}

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, pain or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[13] People having chemotherapy should tell the practitioner first about low blood counts or low platelets, blood thinners, a recent fever, an implanted port, lymphedema, pregnancy, or a pacemaker (relevant to electroacupuncture). Your oncology team should know you are receiving acupuncture.

Ayurvedic medicine for Chemotherapy-Induced Neuropathy

The Ayurvedic view

In Ayurveda, numbness, tingling and pain in the limbs are traditionally linked to disturbed Vata, the principle said to govern movement and nerve function. This is a traditional framework, not a biomedical diagnosis.

Therapies that may be used

Ayurvedic care is described as personalized, with customized diets, lifestyle changes, medicines and cleansing therapies.^[14] For someone in cancer treatment it is kept gentle:

• Diet and daily routine intended to calm Vata, such as warm, regular meals and steady sleep hours
• Warm oil massage of the hands and feet, applied gently
• Herbs prescribed by a qualified practitioner, after review of your medicines
• Panchakarma only where traditionally appropriate and medically sensible

Panchakarma is not appropriate during pregnancy, acute illness or frailty, and strong cleansing procedures are generally not suitable during active chemotherapy. Any such procedure would only be considered with your oncology team's knowledge and when it is medically sensible.

What the research shows

The research on Ayurveda for CIPN is very limited. A PubMed search found no clinical trials, only a case report of one patient with taxane-related CIPN who improved after an individualized Ayurvedic program of diet, lifestyle, medicines and detoxification therapies.^[14] A single case cannot show that the treatment caused the improvement.

Herbal medicine for Chemotherapy-Induced Neuropathy

Herbs and formulas that have been studied

Studies have looked at traditional Chinese herbal formulas given with chemotherapy and at the Japanese herbal formula Goshajinkigan, mostly to prevent CIPN or reduce its severity.^{[15, 16]} No specific Ayurvedic herb has been tested in a clinical trial for CIPN that we found.

What the research shows

The evidence is limited. A meta-analysis of 63 trials in colorectal cancer found that integrative herbal medicine appeared to reduce severe CIPN with some grading scales but not others. The authors noted the lack of blinding, risk of bias and short follow-up.^[15]

For Goshajinkigan, two meta-analyses of five trials each reached similar conclusions. One found it unlikely to prevent CIPN and advised against standard use given low-quality evidence, and the other found it did not reduce the risk of CIPN with the main grading scale.^{[16, 17]} The Society for Integrative Oncology breast cancer guideline found no strong evidence that ingested supplements help manage treatment side effects.^[4]

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines, which matters during cancer treatment. Reviews describe interactions with many prescription drugs, including blood thinners, and case reports describe bleeding when warfarin was combined with herbs including dang gui (Angelica sinensis), dan shen (Salvia miltiorrhiza), ginger, ginseng and Boswellia.^{[18, 19]} The guideline also cautions against acetyl-L-carnitine for preventing CIPN because of possible harm.^[4]

Herbs should not be started without your oncologist's knowledge. In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, or have surgery planned.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes numbness and pain in the limbs as qi and blood failing to nourish or flow through the channels, sometimes with cold. Researchers studying CIPN look at things that loosely parallel this picture: damage to sensory nerve fibers, altered nerve conduction and the way pain is processed.^{[1, 12]}

Ayurveda's disturbed Vata describes numbness and pain with unsteady movement. No study has shown that a dosha or a pattern corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for CIPN is complementary and supports symptoms; it does not treat the cancer. Keep your oncologist, and do not stop or change chemotherapy or other prescribed medicines without your prescriber. Report new or worsening neuropathy to your oncology team promptly, since they may adjust treatment.^[2]

Exercise has the clearest supporting evidence for function, so ask your team about it as well.^[5] Please bring your cancer diagnosis, your chemotherapy schedule and list of drugs, recent blood counts, a full list of medicines and supplements, and notes from your oncologist or physical therapist.

When to seek urgent medical care

Call your oncology team promptly for new or worsening neuropathy, and seek emergency care for symptoms that could be serious.^[2]

• Fever or chills during chemotherapy, which can mean a dangerous infection
• New weakness in the arms or legs, or falls and severe trouble walking
• Sudden loss of bladder or bowel control, or numbness in the groin
• Burns, cuts or sores on numb hands or feet that you did not feel, or that are not healing
• Sudden severe pain, or numbness spreading quickly up the limbs
• New confusion, trouble speaking, or weakness on one side of the body

If any of these occur, call 911 or go to the nearest emergency department.