Disclaimer: The views and opinions expressed in this presentation reflect those of the speakers and do not necessarily reflect those of the United States Department of Veterans Affairs.
Peripheral neuropathy is a disease of the peripheral nervous system
Simple definition, but this umbrella term encompasses soooo many different types of neuropathies.
Common peripheral neuropathies can include length-dependent sensory-motor neuropathies (like diabetes-related neuropathies), chemical exposure-related neuropathies (hello CIPN), & idiopathic neuropathies.
Evaluating the person with peripheral neuropathy
Dr. Gomes recommends a comprehensive sensory screen, no matter the cause of neuropathy. At bare minimum, you should include monofilament (specifically 5.03 monofilament for protective sensation) & vibration testing.
Additionally, you should be checking foot & ankle strength, followed by functional assessments like single leg balance.
Dr. Gomes also recommends outcome measures like the DGI or FGA, especially when tracking changes that may occur with exposure to neurotoxic chemotherapies or immunotherapies.
Depending on the nerves that are affected, your patient may have different symptoms with their neuropathy. Patients affected by small fiber neuropathy may have more pain, paresthesias, temperature loss, & even autonomic issues.
On the other hand, patients with larger fiber neuropathies may experience painless paresthesias, loss of vibration, proprioception, & potentially even deep tendon reflexes, not to mention decreased strength.
Don’t forget these important evaluation components for peripheral neuropathy:
Balance & falls is absolutely a concern for patients with neuropathy, but they are far from the ONLY issue these patients can face.
Skin issues are especially important to check for & on your patients with neuropathy. Dr. Gomes recommends turning skin checks into an immediate education opportunity to implement DAILY skin checks.
Additionally, patients should be screened for vestibular issues. Ask them about lightheadedness, dizziness, vertigo, hearing loss, or ear ringing.
Red flags still count with neuropathy
In this episode, Dr. Gomes & I shared some patient cases that you’ll definitely want to hear if red flags make you nervous.
But it all comes back to basics. Common neuro red flags include sudden changes in speech, swallowing, vision, bowel/bladder control, numbness or tingling in the face.
Treating your patient with peripheral neuropathy
As with all things in PT, it depends. But here’s some actual helpful tips from Dr. Gomes:
If a person has decent foot/ankle strength, you may be able to strengthen those muscles to improve foot drop. However, some patients may need more compensatory strategies because they may not recover full function.
Balance/stability/vestibular training is massively important from a safety standpoint. Dr. Gomes also recommends using the Rating of Perceived Stability Scale with your patients, especially with your balance/stability interventions.
Products Dr. Gomes discussed:
Further recommended reading:
- Peripheral Vestibular Hypofunction Clinical Practice Guideline
- Effect of Low-Intensity Physical Activity and Moderate- to High-Intensity Physical Exercise During Adjuvant Chemotherapy on Physical Fitness, Fatigue, and Chemotherapy Completion Rates: Results of the PACES Randomized Clinical Trial
- Effects of exercise on cancer patients suffering chemotherapy-induced peripheral neuropathy undergoing treatment: A systematic review
- Effects of Exercise during Chemotherapy on Chemotherapy-Induced Peripheral Neuropathy: A Multicenter, Randomized Controlled Trial
About Dr. Kayla Gomes, PT
Dr. Kayla Gomes, PT, is a Neurologic Clinical Specialist who has gained experience working in multiple settings with varied patient populations; including hospital based outpatient, inpatient rehab, and acute care. She has had the pleasure of working within an interdisciplinary team to successfully publish a manuscript in The Journal of Neurologic Physical Therapy. Her commitment to clinical education includes acting as a Credentialed Clinical Instructor as well as completing a project to address burn out and improve resilience for stakeholders in ClinEd during the COVID 19 Pandemic. She is an active member of the American Physical Therapy Association and was selected as the 2021 Centennial Scholar for the CT Chapter of the APTA. She currently serves as a Delegate representing the CT Chapter at the APTA’s National House of Delegates.
Contact Dr. Gomes at KaylaGomesPT@gmail.com or follow her on Twitter/X @NU_DPT
Transcript
Elise – @TheOncoPT (00:01.174)
The views and opinions expressed in this presentation reflect those of the speakers and do not necessarily reflect those of the United States Department of Veterans Affairs. That’s the first time I’ve ever had to read a disclosure like this on the podcast and it makes me feel very important right now. Like, I have made it to where I have a big head honcho guest who is like involved in the government now. Like this is a first Kayla so I’m really excited. Woo!
Kayla Gomes (00:16.053)
Very official.
Kayla Gomes (00:25.569)
Government employee.
Elise – @TheOncoPT (01:23.846)
I am so thrilled today to have a very important guest on the Onco PT podcast to talk all about neuropathy, specifically from a neuro, or as I have learned today a new phrase, northopet. So the neuro, neuroortho lens on neuropathy and then how she is really taking that and applying this to some of her more medically complex patients, including some of her patients with cancer.
So I’m so thrilled to welcome Dr. Kayla Gomes to the Onco PT podcast. Kayla, welcome.
Kayla Gomes (01:58.977)
Thank you. So excited to be here. Thanks for letting a neuro or northo PT invade in the onco PT space. I love it.
Elise – @TheOncoPT (02:08.21)
Oh, we’re here for it. We’re here for it. Would you mind just telling us a little bit about yourself, how you got started in PT, and maybe even a little of like what drew you to the neuro side of things?
Kayla Gomes (02:14.369)
Sure. OK.
Kayla Gomes (02:22.273)
Sure. So I went to PT school thinking I was going to be a hand therapist, actually. I know, it’s very random. I ended up falling in love with the neuro content and I was a PCA for a gentleman who had an incomplete spinal cord injury and hired PT students from our PT school and he was really into working out super hard so I got some of that high intensity very early on in my career before I even knew.
Elise – @TheOncoPT (02:51.079)
exciting.
Kayla Gomes (02:53.713)
So when I left PT school, I was interested in pursuing this interest in neuro. I applied and interviewed at, I think, three neuro-residencies, and I didn’t get into any of them. And at the time, it was really devastating because that was the first time academically I hadn’t been successful at something.
Elise – @TheOncoPT (03:00.713)
Mm-hmm.
Elise – @TheOncoPT (03:20.848)
Mm-hmm.
Kayla Gomes (03:21.541)
So I took some time to be sad about it and reflect because, you know, I was very green. I had great clinical placements, but none of them were really in neuro. So in hindsight, I don’t think I would have gotten the most out of residency anyway, and some of my interviews weren’t exactly strong. So I was like, okay, what do I do? And so then I applied to jobs all up and down the East Coast, and I was looking for a job that
Elise – @TheOncoPT (03:39.95)
Mm-hmm.
Kayla Gomes (03:49.609)
not only had mentorship, but I could see everything, not just neuro, but everything else, just to really make sure I liked it. And I was very lucky at my first job. I had great mentorship, great coworkers, and I got to see everything. I saw neuro, I saw ortho, and I saw a lot of medically complex patients, which is something that I really loved. They even had an oncology program there.
Elise – @TheOncoPT (03:57.816)
Mm-hmm.
Kayla Gomes (04:16.933)
my mentor handed me like the star, like level one packet and was like, here you go. You seem to be interested in this. So that, so that’s how I was introduced to oncology. So then eventually I did get my NCS during COVID. All my hobbies were canceled. I’m like, I’m going to do this now. So I ended up getting the NCS and at that last job, I saw mostly central.
Elise – @TheOncoPT (04:22.626)
Ha ha!
Kayla Gomes (04:46.737)
sort of neuro, so MS stroke, concussion, brain injury. But now I’m at the VA, and that’s more peripheral neuro disorder. So I see neuropathy, falls, balance, vestibular, but from my first job to now, I really like having a varied caseload, so I really do see everything. I see neuro, ortho, this medically complex population.
Elise – @TheOncoPT (04:57.014)
Yeah.
Kayla Gomes (05:17.045)
I like seeing it all and I didn’t coin the term North O-P-T, but I do like it. I will use that to describe myself and my practice today. Yeah.
Elise – @TheOncoPT (05:21.591)
Ha ha!
Elise – @TheOncoPT (05:27.342)
like that.
Like I said, I heard it first from Kayla literally today. So in my mind, like she has, she invented the phrase. So that’s what we’re going with. When you were first starting to work with this patient population, let’s kind of shift more into like your current work, which is more of the peripheral neuro issues here. One of the things that you and I were talking about off air is like, neuropathy is kind of hard. Like it’s kind of hard to treat. It’s kind of frustrating.
Kayla Gomes (05:34.693)
Yeah.
Kayla Gomes (05:45.939)
Mm-hmm.
Kayla Gomes (05:53.681)
Yeah, yeah, totally.
Elise – @TheOncoPT (05:58.54)
for the audience who’s maybe like a little newer, like they understand, they’ve heard the word neuropathy before, but can we establish a definition of what we’re working with here?
Kayla Gomes (06:07.561)
Absolutely. I get patients all the time who come in and say, the doctor says I have neuropathy, what is that? And I have to pause because I’m like, what’s neuropathy or what’s your neuropathy? Because neuropathy is an umbrella term. It just means like a disease of the nervous system. And if we’re talking about peripheral neuropathy, obviously it’s a disease of the peripheral nervous system. But like, you know, a guillain-barre is considered a peripheral neuropathy. That’s typically not what patients are coming in.
Elise – @TheOncoPT (06:19.314)
Right, ooh. Mm-hmm.
Elise – @TheOncoPT (06:25.826)
Mm-hmm.
Elise – @TheOncoPT (06:29.912)
Mm-hmm.
Kayla Gomes (06:37.333)
to see me for. They’re typically seeing me for this length-dependent sensor motor neuropathy, usually in my population caused by diabetes, or chemical exposures from things like chemotherapy or with my VA population Agent Orange. So that’s a very unique exposure that can cause neuropathies. Other things that can cause neuropathy.
Elise – @TheOncoPT (06:49.045)
Okay.
Elise – @TheOncoPT (06:57.503)
Mm-hmm.
Elise – @TheOncoPT (07:03.694)
Mm-hmm.
Kayla Gomes (07:08.161)
Alcohol use is a big one that I see in my population as well.
Elise – @TheOncoPT (07:09.72)
Mm-hmm.
Kayla Gomes (07:16.233)
And then there’s just this idiopathic neuropathy that becomes more common as people age. That can be very challenging for people to accept because they’ll say, I did everything right. I don’t have diabetes. I don’t drink. What the heck is going on here? So just trying to manage that is somewhat different. And then do you wanna talk about like the evaluation, the treatment, or you wanna talk more about
Elise – @TheOncoPT (07:33.209)
Yeah.
Kayla Gomes (07:45.833)
like bringing it to oncology again. Different treatments can cause various levels of neuropathy or different types of neuropathy. Yeah, yeah.
Elise – @TheOncoPT (07:48.923)
Yeah. So.
Elise – @TheOncoPT (07:54.722)
Yeah. Yes. That’s, I think it’s, that’s one of the things I’m reflecting actually now. I had a patient previously who was a veteran of the Vietnam War and his cancer was actually caused by Agent Orange and I didn’t even think to go that way in this conversation today, but it just brings back like memories of, oh my God, like I completely forgot about that patient. So that is so interesting. See, my patient had, what did he have?
Kayla Gomes (08:05.386)
Yeah.
Yep.
Kayla Gomes (08:13.521)
Yeah. Yeah, a lot of prostate cancer. Yeah. Mm-hmm. Cancers of all types, but a lot of prostate cancer, especially.
Elise – @TheOncoPT (08:23.114)
He had a head and, yeah, he had a head and neck cancer. And he developed it like really early on. That is interesting. We might have to talk more about this off air because I’m really…
Kayla Gomes (08:36.101)
Okay, will do. Yeah.
Elise – @TheOncoPT (08:38.05)
There’s some gears turned on already, which is fun. Let’s kind of take it back a little bit to more of like establishing our baseline of neuropathy. So we’ve talked about, you know, definitely like this chemical exposure. Now in oncology, a lot of times it tends to be the, you know, chemotherapies. We’re seeing some immunotherapies that are even contributing here. But one of the things we really haven’t talked about on the OncoPT podcast yet,
Kayla Gomes (08:40.233)
Yeah.
Kayla Gomes (08:46.721)
Sure.
Kayla Gomes (08:50.332)
Mm-hmm.
Kayla Gomes (08:57.234)
Yeah.
Elise – @TheOncoPT (09:03.134)
is that we know neuropathy is a thing. We know that CIPN, definitely a concern, but we don’t really talk about the fact that this may not be our patient’s first rodeo with neuropathy. And I think we need to talk a little about that.
Kayla Gomes (09:06.17)
Mm-hmm.
Kayla Gomes (09:17.399)
Right.
Kayla Gomes (09:22.081)
So, right, because a patient could have diabetes in dealing with neuropathy. A lot of the time that can be progressive, especially if they don’t have good control of their diabetes, and then you’re adding a secondary neuropathy on top of it, which can be very challenging. So in that sort of situation, what I would do is, if you have the ability to evaluate your patient prior to their cancer treatment.
do it and do a pretty extensive sensory screen and evaluation. What I typically do is at least monofilament and vibration testing. And that 5.03 monofilament for protective sensation. You can get real nitty gritty into like sharp dull if you want. And also
Elise – @TheOncoPT (10:00.373)
Mm-hmm.
Elise – @TheOncoPT (10:07.112)
Yeah.
Elise – @TheOncoPT (10:11.608)
Mm-hmm.
Kayla Gomes (10:20.341)
foot and ankle strength, and then looking at some of the more functional things like single leg balance and then moving way into things like doing a DGI or an FGA so that you can track change. That’s going to be really important with those populations that might have a pre-existing neuropathy from another disease or chemical process who might be going through another chemical process on top of it.
Elise – @TheOncoPT (10:33.658)
Mm-hmm.
Elise – @TheOncoPT (10:46.814)
Mm-hmm. So when you have a patient coming in, and like, let’s say you’ve got a chart in front of you, right, like you’ve got the chart from the physician, but you don’t have a lot more information than that. You know that they’ve got neuropathy, you don’t exactly know what it’s caused by. If this is a diabetic neuropathy, if this is a CIPN, is this a both situation? When that patient comes in the door, how are you starting your evaluation with that patient?
Kayla Gomes (11:03.263)
Mm-hmm.
Kayla Gomes (11:14.757)
a really thorough subjective history.
Elise – @TheOncoPT (11:18.35)
Okay.
Kayla Gomes (11:19.893)
because neuropathy can cause a lot of things, right? And I guess I should have mentioned this in the beginning with what’s a neuropathy. It’s a disease of the nervous system and your symptoms are gonna be dependent on which nerves are affected.
Elise – @TheOncoPT (11:35.766)
Mm-hmm.
Kayla Gomes (11:37.365)
So if we’re talking more like small fiber neuropathy, they could have a lot of pain, they’re in peristesias, they could lose temp, oh my God, not management of temperature, sensation of temperature. You might see with some of those small fiber neuropathies, even autonomic neuropathies too. So they could have some orthostatic hypertension.
Elise – @TheOncoPT (12:02.019)
Mm-hmm.
Kayla Gomes (12:06.565)
If we go more to large fiber, you’re going to see more like painless peristegios, they might not feel anything, even like deep pressure. They might start losing vibration, proprioception. And that’s where you start to see changes in skin and even some loss of deep tendon reflexes and weakness of the foot and ankle. So.
Elise – @TheOncoPT (12:15.98)
Mm-hmm.
Elise – @TheOncoPT (12:29.323)
Mm-hmm.
Kayla Gomes (12:34.261)
kind of lost my train of thought. Where was that question going? I’m just going.
Elise – @TheOncoPT (12:38.062)
So the first question I asked was like, how do you start your evaluation with these patients? And you said a very thorough subjective answer. So then we took it back to small versus large fibers. And I have a followup after you finish your thought because you brought up something I’m really excited about.
Kayla Gomes (12:46.018)
Right. So…
Kayla Gomes (12:53.437)
Right. So, you know, depending on what nerves are affected, you’re gonna have all these different types of symptoms. The two biggest complaints are pain and imbalance. Those are the big two that I deal with. And typically, patients are referred to me because they’re falling.
Elise – @TheOncoPT (12:58.531)
Mm-hmm.
Elise – @TheOncoPT (13:14.43)
Yep, that sounds familiar.
Kayla Gomes (13:16.297)
because they’re falling. I would love, and this can go with many diagnoses, not just neuropathy or people who are going to go through cancer treatments, I would love if my patients got to me earlier. Ha ha ha. Because if they’re already falling, it’s challenging, right? So, where do you, like, okay, I have neuropathy.
Elise – @TheOncoPT (13:26.51)
Mm-hmm.
Elise – @TheOncoPT (13:32.134)
I feel that so deeply.
Elise – @TheOncoPT (13:37.01)
Yeah.
Kayla Gomes (13:45.461)
Do you feel anything? Do you have numbness or tingling in your feet? Is there any pain associated with that? Because a lot of my patients, by the time they get to me, they don’t even feel their feet at all.
Elise – @TheOncoPT (13:49.201)
Mm-hmm.
Elise – @TheOncoPT (13:56.279)
Yeah.
Kayla Gomes (13:58.421)
So then I start asking questions about their inner ears. Specifically, like, do you have any history of lightheadedness, dizziness, vertigo, any history of hearing loss or ear ringing? Because I’m thinking of the big three inputs to balance, vision, vestibular, and somatosensory. So if I know we’re already lacking some somatosensory input,
I’m already thinking ahead to, okay, what can I help my patients use to kind of retrain their balance system? And I got to tell you, with my patient population, they’re older, they have exposure, like occupational exposures, gunfire, blasts, that can cause vestibular hypofunction. So now we’re not just dealing with the neuropathy in their feet. We’re dealing with…
Elise – @TheOncoPT (14:37.674)
Mm-hmm.
Elise – @TheOncoPT (14:50.026)
Right?
Kayla Gomes (14:57.929)
of vestibular hypofunction.
Elise – @TheOncoPT (14:59.579)
Mm-hmm.
Kayla Gomes (15:01.429)
So I ask them, you know, you have some numbness and tingling in your feet, you have some pain in your feet, like okay, ever get dizzy and ever get vertigo. Sometimes they don’t know. So then I ask questions such as, when you’re in the shower and you close your eyes, what happens? And a lot of the times they’ll say, I feel like I’m gonna fall over. Or I grab the wall or I grab a grab bar. That sets off an alarm bell in the back of my head, like okay, we’re probably dealing with some vestibular stuff, right.
Elise – @TheOncoPT (15:13.07)
Mm-hmm.
Elise – @TheOncoPT (15:21.614)
There we go.
Elise – @TheOncoPT (15:30.774)
Mm-hmm.
Kayla Gomes (15:32.373)
um any orthopedic problems you know before the neuropathy or after um you are talking about before patients who have other neuropathies or pre or like pre-morbid comorbidities you know think of a lumbar
Elise – @TheOncoPT (15:50.23)
Mm-hmm
Elise – @TheOncoPT (15:57.863)
Mm-hmm.
Kayla Gomes (15:58.971)
So they might come to me and say, yeah, I’ve had sciatica forever that goes all the way down to my foot, but now I’m starting to feel like numbness and tingling in both of my feet. Is that from my back?
Probably not. Right, we probably have two things going on at once. Right, so I guess with my subjective, it’s why are you falling? What is your current sensation? Trying to figure out what their vestibular system and their visual system might look like. And then taking it to my exam from there.
Elise – @TheOncoPT (16:09.826)
Yeah.
Elise – @TheOncoPT (16:13.994)
Right?
Elise – @TheOncoPT (16:30.412)
Mm-hmm.
Elise – @TheOncoPT (16:38.506)
I’m really excited. A couple different things. So I want to take it back actually a little bit. I’m so thrilled that when we were initially talking about small fiber issues, right? You mentioned of course like we’ve got some sensory potentially like motor issues here, but what you also mentioned is autonomic dysfunction. And Kayla, I kid you not, it took me like two years, maybe three years into my practice before I genuinely understood that neuropathy is
Kayla Gomes (16:47.847)
Mm-hmm.
Kayla Gomes (16:56.937)
Yeah.
Kayla Gomes (17:06.695)
Mm-hmm.
Elise – @TheOncoPT (17:08.56)
not just a sensory motor issue. Like it can also be autonomic and it makes me giggle now because I’m like oh my god like I knew so little back then but now I’m also like what was I missing? Like what clues were I missing in my patient who like had definite neuropathy and I just did not put it together that their autonomic issues were related to the neuropathy?
Kayla Gomes (17:11.845)
Right.
Kayla Gomes (17:33.297)
Right, especially with some of these systemic causes of neuropathy. I say to my students, and I say this tongue and cheek, but I’m like, the vestibular cochlear nerve, it’s a nerve. Right? So if we’re thinking of diabetes and how it can affect the nerves in the hands and the feet, why not the inner ear? And it does, if you look at the research for diabetics, a lot of…
Elise – @TheOncoPT (17:37.834)
Yeah!
Elise – @TheOncoPT (17:52.502)
Mm-hmm.
Kayla Gomes (17:58.865)
they have more vestibular issues than age match and, you know, comorbidity match controls. And I had this conversation with Scott Capozza at CSM because I’d been at the time I was doing a ton of reading on like different types of neuropathies or not neuropathies, different types of chemotherapy and how they can cause neuropathy. And I must have had a patient who I must have had a patient with cancer at that point. That’s why I was looking into it. And they kept talking about
Elise – @TheOncoPT (18:04.858)
Mmm.
Elise – @TheOncoPT (18:09.928)
Ah, yes.
Elise – @TheOncoPT (18:18.668)
Yeah.
Kayla Gomes (18:28.649)
the platinum agents and how some of those are ototoxic. But they didn’t talk about any other chemotherapy. And I read one paper that even said, oh yeah, it can cause neuropathy, it can cause CIPN, like the sensor motor thing, but it’s sparing to the vestibular cochlear nerve, to the inner ear system. And I’m like, how is that possible? I don’t think that, I don’t think, and I did a ton of reading before I came here today, because I was like, did I imagine that wrong?
Elise – @TheOncoPT (18:32.216)
Mm-hmm.
Elise – @TheOncoPT (18:49.834)
Yeah, how? How? What?
Elise – @TheOncoPT (18:55.775)
Yeah.
Kayla Gomes (18:57.961)
There really isn’t much out there looking at anything but these platinum agents in the ototoxicity. Like the hearing loss and some of the vestibular loss you can have with those agents. Whoever’s listening out there who does a lot of research regarding chemotherapy agents, you should look into that. Like how different types of chemotherapy may result in vestibular loss. We already have the research that it shows.
Elise – @TheOncoPT (19:04.67)
Yeah. That’s interesting.
Kayla Gomes (19:24.221)
core balance, but everyone just talks about the sensor motor piece. They can’t feel their feet. They lose that proprioception. Well, what about their inner ear? That’s just my little soap box that if I had more time, I would research into.
Elise – @TheOncoPT (19:28.022)
Right. Mm-hmm.
Elise – @TheOncoPT (19:35.15)
No, totally. And that’s, you know, like, first of all, vestibular system. I mean, we’re already talking about patients having falls and balance problems and being a fall risk. Like this is already an issue, even if we’re just talking about like the sensory motor side of things. But then you throw in that and then thinking about, you know, gosh, chemotherapy has so many different side effects anyways. And I think a lot of times, at least in my world, Kayla, and I’m curious if you have this perception or perspective too.
Kayla Gomes (19:42.686)
Right.
Kayla Gomes (19:56.49)
Yes.
Elise – @TheOncoPT (20:05.118)
We kind of throw a lot of side effects on chemotherapy of like, oh, it’s just chemotherapy, you know, like, wow, whatever. Without really considering this may actually be a neuro, a neuropathy issue thinking about.
You know, some chemotherapies cause GI distress and GI issues. Yeah, totally. The chemotherapy definitely affecting those mucosal, you know, linings, etc, etc. But some of those, it goes deeper than just mucosal irritation, right? Like there’s other things. Yeah. Oh man.
Kayla Gomes (20:33.777)
the autonomic nervous system. Yeah. Oh man, I agree.
Elise – @TheOncoPT (20:41.498)
Okay, before I get too sidetracked again, because I’m like, I’m just, it makes me so excited that we’re talking about autonomic stuff because I missed that so badly for like, several years of my practice initially. Yeah!
Kayla Gomes (20:48.199)
Mm-hmm.
Kayla Gomes (20:52.865)
I feel like it’s not taught as well in schools. Yeah, I think there’s more of it now because of COVID. And if you’ve done a lot of study into concussion, you’ll learn a lot more about the autonomic nervous system. But speaking for myself, I don’t think I got a lot of autonomic nervous system consideration in PT school.
Elise – @TheOncoPT (21:00.474)
Mm-hmm. That’s a good point. That’s a really good point.
Elise – @TheOncoPT (21:08.084)
Mm-hmm.
Elise – @TheOncoPT (21:14.414)
Mm-hmm. That does make me feel like five percent better. If you didn’t and you’re like a neuro person, then I feel a little better. You know, and it’s interesting because we have some literature.
Kayla Gomes (21:21.062)
Yeah. Mm-hmm.
Elise – @TheOncoPT (21:28.966)
about CIPN and we’re getting more every year but a lot of what informs our practice in a lot of situations is really like diabetic neuropathy and that’s definitely like there’s a lot of ties but we also can’t forget like there are there are also some differences like we should probably be aware of with all this.
Kayla Gomes (21:31.562)
Yeah.
Kayla Gomes (21:39.045)
Yes, exactly. Yeah.
Kayla Gomes (21:46.337)
Mm-hmm. Yeah. Yep, exactly.
Elise – @TheOncoPT (21:51.474)
Okay, I’m gonna reel it back in. So, we’re going back to our evaluation now. You have taken a very extensive subjective history. You’ve asked a ton of questions on what are they experiencing, how are they experiencing it, kind of like the when, what are the circumstances in which they’re experiencing that. So you’ve got this subjective information. What are you then going to do in your evaluation of this patient?
Kayla Gomes (21:53.185)
I’m going to go to bed.
Kayla Gomes (21:59.535)
Mm-hmm.
Kayla Gomes (22:06.529)
Mm-hmm.
Right.
Kayla Gomes (22:17.057)
I’ll do a sensory exam. If you look at the diabetic neuropathy literature, I read somewhere that the best sensitivity and specificity with all the tests is if you do monofilament and vibration combined. So that’s typically what I do. It really doesn’t take a lot of time. And I’ll get on my soap box for a second. For your patients with neuropathy, especially diabetic neuropathy, you need to check their feet. You need to check their skin.
Elise – @TheOncoPT (22:34.99)
Mm-hmm. Yeah. Yes, please.
Kayla Gomes (22:44.457)
So if you’re doing a sensory exam anyway, you should be taking off their shoes and their socks. But I can’t tell you the number of times I have found wounds, splinters, you know. And I use that sensory exam as an immediate educational moment. When I show them the monofilament and I say, let me know if you feel this at the bottom of your feet and if you can wear.
Elise – @TheOncoPT (22:48.107)
Right?
Kayla Gomes (23:12.445)
If they don’t feel any of that, I explain this little fishing line looking thing is called protective sensation, right? So it’s looking at if you have a small rock in your shoe or a bunch in your sock or your shoe is bothering you, you’d be able to feel it. But you don’t have that sensation. So then my next question is, do you check your skin every day? Most of the time they say no. And I say, you’re going to start.
It’s going to be something like brushing your teeth. You’re going to do it every day. And if they lack the range of motion or strength to do that, I’m very lucky. I work at the VA. I can order equipment that I think is medically justified. I immediately order them an extendable mirror to check the bottom of their feet every day.
Elise – @TheOncoPT (23:56.898)
Yes. Very nice.
Kayla Gomes (24:00.693)
So, you know, I also am the amputee PT person at the VA. And for patients who might not really get it or wanna know more, I say, you know what? This is really important. Cause if you got a cut or a wound, you might not be able to feel it. And the consequences of that can be really extensive. Like we’re talking infections, we’re talking amputations. And no one wants to think about that, right?
Elise – @TheOncoPT (24:06.274)
Mm-hmm.
Elise – @TheOncoPT (24:29.91)
Right, right.
Kayla Gomes (24:30.953)
So I’ll do a sensory exam. I’ll check their strength up and down the chain. So I’ll check toe strength, you know, just distally first to see what their strength is doing. Dorsiflexion, inversion, eversion, knee flexion, extension, hip, all planes, because that might also affect their ankle and hip and stepping reactions later.
Elise – @TheOncoPT (24:42.456)
Mm-hmm.
Elise – @TheOncoPT (24:59.652)
Mm-hmm.
Kayla Gomes (25:01.425)
Um, and then I personally do a vestibular ocular screen on all my neuropathy patients, every single one, because of that three systems thing, right? If someone has neuropathy, diabetic, chemotherapy, Agent Orange, and realistically, I don’t think I’m going to be able to…
Elise – @TheOncoPT (25:11.246)
Mm-hmm.
Kayla Gomes (25:26.609)
improve that somatosensory system, what are we going to rely on instead? So if their vestibular system, you know, they have a hypofunction on one side or both sides, or they have dizziness or vertigo that’s chronic or acute, my prognosis is going to be a little more guarded than those who have that intact.
Elise – @TheOncoPT (25:32.541)
Mm-hmm.
Elise – @TheOncoPT (25:51.869)
Mm-hmm.
Kayla Gomes (25:53.377)
That’s just the reality of it. And for those who are lacking that somatosensation and that vestibular input and that visual input sometimes because of diabetic retinopathies or cataracts or whatever it is, if you’re missing two out of the three or three out of the three of those inputs, I started thinking about more compensatory strategies. Grab bars in the shower.
Elise – @TheOncoPT (26:20.466)
Mm-hmm.
Kayla Gomes (26:23.285)
shower chairs and shower benches. Again, I’m very fortunate the VA, that’s something that I can just dispense if I think it’s medically justified. Canes, walkers, not because they have a weakness, but because their brain just needs something to help them orient in space. That would come out in the subjective history too, if they’re wall walkers or furniture walkers. Yeah. And then…
Elise – @TheOncoPT (26:44.005)
Mm-hmm.
Elise – @TheOncoPT (26:49.49)
Yo. Oh man. Oh my god.
Kayla Gomes (26:52.881)
And then I try to do some sort of functional outcome measure, tying it to what they have the most trouble with. I like the DGI and the FGA. I really like the mini best test, but it takes a little bit longer. Tug five times sit to stand if they came late to their appointment and we don’t have enough time, if I’m being totally honest. Yeah, yeah. And then we go from there.
Elise – @TheOncoPT (27:08.142)
Mm-hmm.
Elise – @TheOncoPT (27:14.55)
Right? Right, I’m here for it.
Kayla Gomes (27:22.901)
That’s what my evaluation typically looks like.
Elise – @TheOncoPT (27:25.966)
I like that. So kind of zooming in on some stuff. We had previously mentioned this off air, but I want to bring it back. So if you’re working with a patient, what are some potential signs of something else is wrong here? Something like something is not right as far as like red flags, even like some orange, like I’ve heard them like orange yellow flags, right? Yeah. So what are some of those that you might be looking for in this patient population with neuropathy?
Kayla Gomes (27:32.48)
Mm-hmm.
Kayla Gomes (27:42.612)
Yeah.
Kayla Gomes (27:47.354)
Orange flags, yeah.
Kayla Gomes (27:54.041)
Yeah, and I work at the VA where it is direct, true direct access. So, or they’ll call up their PCP and be like, I’m having trouble walking. I want to see PT and they don’t really have any diagnostics. Um, your typical neuro red flags are important to remember going back to the oncology population with some of these brain mets or spine mets, right? Like if there is a sudden change in, um, uh, speech swallowing.
Elise – @TheOncoPT (27:59.854)
Amazing.
Elise – @TheOncoPT (28:07.982)
Mm-hmm.
Elise – @TheOncoPT (28:17.823)
Right?
Kayla Gomes (28:23.941)
vision, bowel and bladder control, numbness or tingling in the face.
Kayla Gomes (28:34.229)
perhaps like unilateral numbness or tingling and like gross weakness, right? Like these more stroky central signs. And sometimes I get people who are really panicked looking at somebody’s gate and they call it an ataxia. That’s another pet peeve of mine. Everyone who has, you know, gate deviations is an ataxia. I’m like, that’s not what ataxia is. But asking the question like, okay.
Elise – @TheOncoPT (28:39.62)
Mm-hmm.
Kayla Gomes (29:03.325)
You have this wide base of support. You’re holding onto walls. Do you feel really in balance? Has this been going on for a long time? Or you woke up with this 10 out of 10 headache. You’re really dizzy and now you can’t walk unassisted. That’s when we started thinking about like a HINTS exam, right, to rule out like a posterior circulation stroke. Less red flaggy things.
vertical apathy’s like is it just unilateral because you can see unilateral numbness or tingling or unilateral my atoma weakness in those situations But with a lot of these signs you can rule it in or out with your subjective history or with your exam Right, if you’re checking reflexes and they’re hyper reflexive instead of hypo reflexive or absent That’s a central sign. That’s not a sign of neuropathy
Elise – @TheOncoPT (29:35.246)
Mm-hmm.
Elise – @TheOncoPT (29:40.854)
Mm-hmm.
Elise – @TheOncoPT (29:46.847)
Mm-hmm.
Elise – @TheOncoPT (29:54.378)
Mm-hmm.
Elise – @TheOncoPT (29:58.621)
Mm-hmm.
I love how it comes back to basics, like it really does. Ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha
Kayla Gomes (30:04.101)
It really does. Like when I came to the VA and I started, you know, 20 patients of neuropathy and I’m like, oh my God, like I just know stroke and MS, what do I do? It really comes down to basics. It really does. Like your basic clinical skills and exam. Mm-hmm.
Elise – @TheOncoPT (30:15.914)
Right? Oh my god. Yep.
Elise – @TheOncoPT (30:23.802)
Mm-hmm. Did you, in PT school, did you ever hear the phrase of like, if you hear hooves, it’s a horse, or like it’s not a zebra? Okay. I feel like, especially when I was first practicing, yeah, I think as a new grad and as someone new to oncology, everything was a zebra that I was hearing. Like every time I heard hooves, it was a zebra. It was actually a horse most of the time.
Kayla Gomes (30:32.736)
Yes.
Kayla Gomes (30:36.759)
I have mixed feelings about this. I tweeted about this at one point.
Kayla Gomes (30:47.809)
Sure. Yeah.
Elise – @TheOncoPT (30:52.61)
But every once in a while, it was a zebra. Like I had one patient who, I had seen her previously, so I knew what her kind of function was. She came back about six months later and she was totally different. So previously she was ambulatory, independent in all of her stuff, walking around like we were good. Six months or whatever later, she comes in, she is pushed in to the clinic.
Kayla Gomes (30:53.186)
Mm-hmm. Ha ha ha. Right.
Kayla Gomes (31:03.402)
Mm-hmm.
Elise – @TheOncoPT (31:19.102)
in a wheelchair by one of her children. And I was like, oh my God, what is this? And like, right? And so previously, this is one of my very like memorable zebra situations. But again, going back to what Kayla’s saying about, it really does come down to these basics. Like what are these neuroscience that we’re looking for that potentially indicate a problem? And I should have listened to my gut because yes, this was one of those zebra situations. Imaging had actually ruled out metastatic disease. Like we…
Kayla Gomes (31:19.969)
Hmm.
Kayla Gomes (31:23.229)
What happened?
Elise – @TheOncoPT (31:47.958)
were very much on the impression that it was not the case, but she had this radiculopathy. I was like, what is going on? And like I did every back test, like lumbar spine test in the book I could think of. I was like, oh my God, I can’t figure it out, da da. And so like long story short, eventually I gave up and I was like, radiation oncologist, I’m so sorry, like I don’t know what’s going on. We need to do more imaging. And they’re like, okay, sure enough, the first round of imaging had missed it, but there were neuroscience the whole way.
Kayla Gomes (31:57.321)
Yeah.
Kayla Gomes (32:07.645)
It’s like not responding, yeah.
Kayla Gomes (32:13.761)
scary.
Elise – @TheOncoPT (32:18.072)
that I was just like no it can’t possibly it can’t possibly be it but again like if I had yeah so absolutely so for this patient this was a couple years so I’m probably forgetting some details one of the biggest red flags when it comes to pain and oncology is unrelenting pain
Kayla Gomes (32:20.285)
Really?
Kayla Gomes (32:23.817)
Do you feel comfortable sharing what those were? What those neuroscience were?
Kayla Gomes (32:39.029)
Control pain, yeah. Yeah.
Elise – @TheOncoPT (32:41.498)
worse at night. I mean like all of those you know like malignant related pain things she fit all of that. Nothing changed it positioning wise. Gosh I’m trying to think what else she had. The pain was just so extreme. That’s what I was sticking out the most. Okay let’s see she had radiating pain down her back into her butt and then a little bit into her thigh. She did have weakness.
Kayla Gomes (32:46.761)
Right.
Kayla Gomes (32:57.121)
Mm-hmm.
Kayla Gomes (33:09.205)
Mm-hmm.
Elise – @TheOncoPT (33:09.246)
like in that area that was new, it was unilateral, that was, you know, that was a new development. I don’t think she actually had any sensory changes.
Kayla Gomes (33:20.765)
Oh, interesting. I guess it would depend where in the spinal cord. It was, yeah. Yeah.
Elise – @TheOncoPT (33:22.55)
However, this was also like three years ago, so she could have and I just forgot about it. But again, just going back to like, there were basic signs, there were basic red flags that I was like, nah, like, can’t possibly get in, you know, like they already said that it wasn’t the case. So yeah, it’s usually not a zebra, but every once in a while it is a zebra. And those basics would have told me from the beginning it was a zebra and I should have just listened to my gut. Yeah.
Kayla Gomes (33:37.109)
Mm-hmm.
Kayla Gomes (33:48.481)
Thanks for sharing that because these are the things that we learn from. I had a patient who has metastatic cancer. Name a bone, there’s a met there. It’s tough, except for the cervical spine and the skull. He woke up one day, horrific dizziness, and they were like, this is it. It’s in his brain, it’s in his neck. He had BPPV.
Elise – @TheOncoPT (33:57.59)
Mm-hmm.
Elise – @TheOncoPT (34:01.019)
It’s there, yeah. Ugh.
Elise – @TheOncoPT (34:08.103)
That’s good. Oh no.
Elise – @TheOncoPT (34:18.135)
Oh my god, are you serious?
Kayla Gomes (34:19.369)
But like if you talk to the patient, it’s like, when do you get dizzy? When I get out of bed. I feel like I’m gonna fall, I feel like I turn really fast and I’m gonna fall over. How long does it last? Oh, a minute. That’s not like your typical, like a positional vertigo like that isn’t. But because he had cancer and he had these metastatic meds, everyone freaked out.
Elise – @TheOncoPT (34:36.201)
Oh my god.
Elise – @TheOncoPT (34:42.742)
Right.
Elise – @TheOncoPT (34:47.275)
Right.
Kayla Gomes (34:49.265)
And then once we realized it was not we, once they, the referring people, realized that it was BPPV, everyone was freaked out to treat him because of his bone mess. You know, and positioning him, right? Because he had some pain in his back. So it’s like, how are we going to change our repositioning maneuvers to account for that? Yeah, it’s hard.
Elise – @TheOncoPT (35:03.591)
Right.
Elise – @TheOncoPT (35:09.511)
Mm-hmm
Elise – @TheOncoPT (35:14.418)
Do you mind sharing like what you ended up doing to be able to perform those repositioning maneuvers with this patient? Did you end up doing that with this patient?
Kayla Gomes (35:24.565)
So he had some neck discomfort, but no METS. It was just like a tight muscle pain because his posture was not very good. With sacral, lumbar, and thoracic METS, we were able to do the EPLI, but with some position changes and some support with a lot of pillows.
Elise – @TheOncoPT (35:33.866)
Makes sense.
Elise – @TheOncoPT (35:46.834)
Okay. That’s not kind of what I was thinking. Pillows, yeah.
Kayla Gomes (35:50.509)
Yeah, I didn’t get him into like the full 30 degrees cervical extension because it got into his T-spine a little bit. I just kind of tipped his trunk back, like put some pillows underneath the trunk and got it that way. That’s what I did. Yeah.
Elise – @TheOncoPT (35:56.981)
Okay.
Elise – @TheOncoPT (36:01.69)
Yeah. Oh my God. Love that. See? Oh my gosh. See, like you said, Caleb, this is how we learn about these things. Like this is where the real learning happens. I love that.
Kayla Gomes (36:07.73)
I’m sorry.
Kayla Gomes (36:11.121)
Yeah. Yeah, exactly.
Elise – @TheOncoPT (36:16.838)
Okay, so we’ve done our evaluation, subjective, objective. Now it’s time to actually get into a little bit of treatment. Now I know, it depends on the patient. But what are maybe some things that we can get started with for the person who’s experiencing neuropathy? Maybe we’ve even got a little bit of diabetic neuropathy in there on top of some CIPN. What do you think we should do here?
Kayla Gomes (36:26.814)
Always.
Kayla Gomes (36:38.131)
Mm-hmm.
Kayla Gomes (36:42.965)
So if they have intact vision and vestibular input, I would say let’s kind of build that up a little bit. Some of that more substitution type thinking in the vestibular rehab world. That said, if they still have some somatosensation, right? But it’s proximal to the ankle, you can still work on things like ankle, hip, and stepping reactions. I, you know, depending on
Elise – @TheOncoPT (36:51.356)
Mm-hmm.
Elise – @TheOncoPT (36:55.158)
Yeah. Mm-hmm.
Elise – @TheOncoPT (37:09.269)
Mm-hmm.
Kayla Gomes (37:12.021)
how bad their balance is. I start with weight shifting. I start with a lot of stepping forward, alternating forward, backwards, and side to side.
Kayla Gomes (37:26.345)
Yeah, it’s so hard because it really does depend. Something that a lot of people don’t know about. And, you know, I was saying like, okay, I don’t expect to improve their somatosensation. I don’t expect to increase that somatosensation. That’s not exactly true. And not sponsored by either of these companies, but I’ll talk about them. In my VA, we call them sensory aids. So there’s two types.
Elise – @TheOncoPT (37:38.323)
Mm-hmm.
Elise – @TheOncoPT (37:43.478)
Mm-hmm.
Elise – @TheOncoPT (37:47.676)
Love it.
Kayla Gomes (37:56.505)
Okay, a wakasen is a device that I say to patients, it looks like a house arrest ankle, ankle it looks like a house arrest ankle. It goes around the ankle and then there’s a little wire essentially that goes to a sensor that they put at the bottom of their shoe. It kind of looks like an afl but it’s not. It’s very flexible so when they weight shift to their toes or the front of their foot
Elise – @TheOncoPT (38:09.988)
Okay.
Elise – @TheOncoPT (38:18.887)
Okay.
Kayla Gomes (38:25.337)
it will transmit that to the anklet which has vibration on it.
Elise – @TheOncoPT (38:33.331)
Oh my God.
Kayla Gomes (38:33.333)
So what you’re essentially doing is you’re relate your, if they have like a plantar sensation loss, you are replacing that and moving it proximally to a vibratory sense. So if they shift forward, it vibrates the front of the tibia. If they shift backwards, the posterior part of the tibia, medial, lateral, you get it. So, you know.
Elise – @TheOncoPT (38:40.727)
Mm-hmm.
Kayla Gomes (38:58.969)
we can use something like that to retrain their brain to attend to a more proximal part of their leg with the vibratory sense to help them know where they are in space. That’s a very specific type of patient, right? Because they can only really have plantar sensation loss. If they have sensation loss above mid tibia, it might not be efficacious for them.
Elise – @TheOncoPT (39:10.78)
Mm-hmm.
Elise – @TheOncoPT (39:27.362)
Mm-hmm.
Kayla Gomes (39:28.373)
at least in my VA, they have to go through a whole traditional balanced PT plan of care before we trial something like that because they are more expensive. The other option, not sponsored but I love this company and I love this product, Naboso. Do you know what those are? Yeah, they’re called Approprioceptive Insole and it’s just like this thin, thinner than a Dr. Scholl’s
Elise – @TheOncoPT (39:39.361)
Okay.
Elise – @TheOncoPT (39:47.658)
I feel like I’ve heard of it, but I don’t have a lot of experience with it.
Kayla Gomes (39:59.257)
insert that you put into the shoe and it has this harder plastic textured surface on it that looks like little pyramids. So what it’s doing is it’s increasing the amount of input that people have at the bottom of their feet and they have two different levels. One is blue, I think it’s called active, one is gray, it’s called their neuroinsole. Blue is less aggressive than the gray. So
Elise – @TheOncoPT (40:01.311)
Mm-hmm.
Elise – @TheOncoPT (40:15.129)
Yes?
Elise – @TheOncoPT (40:26.804)
Okay.
Kayla Gomes (40:28.233)
going back to my evaluation, if someone has protective sensation intact, I might consider using a neboso just to up that somatosensation input a little bit, right? I don’t put it in someone’s shoe if they don’t have protective sensation. I don’t think that’s a safe thing to do. But for some people, it can be really great. In my experience, I think it works better.
Elise – @TheOncoPT (40:34.368)
Mm-hmm.
Elise – @TheOncoPT (40:39.946)
Right?
Elise – @TheOncoPT (40:45.698)
Totally. Right.
Kayla Gomes (40:57.745)
in people with centrally mediated proprioceptive issues. We use it all the time with patients with MS where their peripheral nervous system was intact. It’s just that the signal and what they were interpreting centrally wasn’t quite correct. So if you gave them a little bit more of that peripheral input, it would be better. Peripheral neuropathies, you gotta try it with people. So with that, I would do like a Romberg and
Elise – @TheOncoPT (41:01.843)
Okay.
Elise – @TheOncoPT (41:13.151)
Yeah.
Elise – @TheOncoPT (41:21.43)
Yeah.
Kayla Gomes (41:26.949)
all those functional tests, Tug, FGA, DJI, whatever, slip those in their shoes and then retest them and see if there’s improvement. Yeah, that’s great. And we haven’t talked about pain quite so much with neuropathy. Neuropathy is hard to treat. I think pain is the hardest thing to treat with neuropathy.
Elise – @TheOncoPT (41:30.826)
Mm-hmm.
Elise – @TheOncoPT (41:35.626)
Oh my God.
Elise – @TheOncoPT (41:42.294)
Yeah. Mm-hmm.
Elise – @TheOncoPT (41:49.24)
Yeah.
Kayla Gomes (41:51.769)
Sometimes with the nebosos, there’s improved pain. I’ve had the most luck with people with CIPN actually, who aren’t necessarily falling, but they have that burning sensation, or it feels like they’re walking on marbles, or it feels like they’re walking on sand, and it’s really unpleasant. I have tried the neboso with them, and I had a guy whose pain was like seven or eight out of 10.
Elise – @TheOncoPT (42:06.83)
Mm-hmm.
Elise – @TheOncoPT (42:11.647)
Yeah.
Kayla Gomes (42:19.345)
all the time and it went down to like one or two out of 10.
Elise – @TheOncoPT (42:23.486)
Oh my God.
Kayla Gomes (42:24.453)
It was like life-changing for him. But again, you have to try it, because for that person it was great, but I tried it again with another patient and it was too much for them and it increased their pain. So, you know, the Neboso are financially a little more accessible to people. They’re like 50 or $70, depending what type you get. Wachesson’s, oh, I don’t know.
Elise – @TheOncoPT (42:32.372)
Mm-hmm.
Elise – @TheOncoPT (42:39.412)
Yeah.
Elise – @TheOncoPT (42:46.916)
Mm-hmm
Yeah.
Kayla Gomes (42:53.365)
for the VA pricing, it’s like $4,500. And I think a vendor could work with you on the outside and like try to get it covered by insurance, but I think it’s typically something that’s out of pocket for the patient. So these are things you gotta consider before introducing them to people or the idea to people. And they can both be used with AFOs. We haven’t even talked about AFOs and people who have like some of that motor weakness. Yeah.
Elise – @TheOncoPT (42:57.604)
Oh, oh, okay. Yeah.
Elise – @TheOncoPT (43:05.994)
Yeah. Right.
Elise – @TheOncoPT (43:13.677)
Yeah.
Elise – @TheOncoPT (43:19.206)
Oh my god. Like foot drop? Huge issue in some of our patients. Yeah. Yes. Oh my god. Yes.
Kayla Gomes (43:23.589)
Yeah. Mm-hmm. Yeah.
Yeah, so sometimes I’ll try that. I’ll try those sensory aids to increase that somatosensory input too.
Elise – @TheOncoPT (43:34.922)
Mm-hmm. I’m really glad you brought up the foot drop, because that’s something, again, I feel like when I first started learning about CIPN as a very, like…
naive student, wide-eyed and bushy-tailed, I was like, oh, neuropathy, numbness and tingling. And then it even meant it, like, I didn’t really understand about the motor side of things. But man, that foot drop is vicious. And I have personally, I haven’t treated a whole lot of them. I’ve had a really, really hard time with foot drop, with neuropathy. And a lot of times we end up, like, I don’t know that I’ve been able to work with the patient to get that function back. Like,
Kayla Gomes (43:49.554)
Right.
Kayla Gomes (43:58.517)
Brutal. Yeah.
Elise – @TheOncoPT (44:16.845)
really moving into like NAFO and like other compensatory strategies because man I am just like I’m not I’m not making progress with that.
Kayla Gomes (44:25.649)
I think it totally depends on how much strength they have. You know, if someone has some tripping and they have like a three plus or four out of five, all right, let’s try some ankle strengthening exercises and see how they fare. But I agree with you, if they’re less than three plus and they’re tripping all the time, you’re gonna have to do something more compensatory. And with that, with…
Elise – @TheOncoPT (44:29.461)
Mm-hmm.
Elise – @TheOncoPT (44:40.036)
Mm-hmm
Elise – @TheOncoPT (44:50.914)
Yeah.
Kayla Gomes (44:52.837)
AFOs and that sensation loss that’s usually accompanied with it. You have to get something more customized too so that It’s in full contact with their skin and they’re not dealing with any skin breakdown issues that they might not be aware of Yeah
Elise – @TheOncoPT (44:59.069)
Mm-hmm.
Elise – @TheOncoPT (45:08.074)
Yeah, yeah, I was, I’m just thinking of our brutal summer that we had here and just like all the sweat in the shoe and oh my god all the rubbing and the friction, ripe opportunity for blisters and so much more with this patient population.
Kayla Gomes (45:16.746)
Oh.
Kayla Gomes (45:25.157)
Yeah, very much so. And patients are so embarrassed to show me their feet and I’m just like, your hands are more gross, really. Like, it’s fine, I’ve seen it all. I’ve seen everything, yeah, a lot.
Elise – @TheOncoPT (45:36.024)
Hahaha
Elise – @TheOncoPT (45:42.142)
You’ve seen a lot of feet, like feet, and I think I tell my patients the same thing. I’m like, I’m not going to see anything on your foot that I haven’t seen before. And I can guarantee I’ve seen grosser feet than what you’re going to show me. So.
Kayla Gomes (45:48.874)
rape.
Kayla Gomes (45:52.349)
Right, exactly. Yeah. And talking about one more thing with pain. I told you I had a really great I went to a really great course at CSM by Dr. Katie Schmidt and she mentioned a manual therapy technique and she had pulled it from like the diabetic neuropathy literature that was taking you know little bits and pieces from like Thai foot massage and joint mobilizations and trigger
Elise – @TheOncoPT (45:55.298)
What? Yeah, go ahead.
Elise – @TheOncoPT (46:05.068)
Yes?
Elise – @TheOncoPT (46:12.284)
Mm-hmm.
Kayla Gomes (46:22.545)
It’s not something that we do the patients, something we have the patients do to themselves. And I tried it with one gentleman and he would get relief after doing it for about two to three hours, but then it would come back. And so he was like, I’m not really into massaging my feet every two to three hours. And then I tried the nebosos and his pain went down my half. I’m like, well, I should have just done that to begin with. Yeah. Yeah, so.
Elise – @TheOncoPT (46:28.139)
Yes.
Elise – @TheOncoPT (46:35.74)
Mm-hmm. Yeah.
Elise – @TheOncoPT (46:40.885)
Ah.
Elise – @TheOncoPT (46:45.868)
Well, that’s what works for that patient, right?
Kayla Gomes (46:49.925)
I feel like I need to mention that manual therapy technique too. Because that course with Dr. Schmidt was just fantastic.
Elise – @TheOncoPT (46:56.814)
Can I tell you a secret? I interviewed her last week.
Kayla Gomes (46:58.773)
Of course.
Elise – @TheOncoPT (47:02.546)
And she like step by step went through it, that technique. So like listeners, if you’re listening to this now, you’re gonna get it very soon. But one of the things, yes, that’s the thing that she talked about is like, I’ve got it on YouTube. Maybe, yeah, I think she has it on YouTube or it’s coming to YouTube. But one of the things that she mentioned that I think just as a principle, I need to be applying more, like more of that repetition intensity over time
Kayla Gomes (47:06.873)
Yeah, perfect. And it’s on her website. Yeah.
Kayla Gomes (47:18.375)
Yeah.
Elise – @TheOncoPT (47:32.62)
a lot of times we see with neuro rehab is that you’ve got to like I think that’s one of my big problems is if I find an intervention like I don’t necessarily do it I do it from an ortho and not like a neuro perspective and that’s one of the things that Katie talked about is like you have to commit to doing this regularly if we’re gonna and like how structured it is and I do think I tend to be more on the ortho side of like
Kayla Gomes (47:34.26)
Yeah.
Kayla Gomes (47:43.449)
over and over and over again. Yeah.
Elise – @TheOncoPT (48:00.382)
few sets of 10 will be fine or whatever. It’s like, I probably should actually be a little more considerate of like the neuro principles of rehab.
Kayla Gomes (48:01.529)
See ya.
Kayla Gomes (48:06.693)
Yeah. And I was talking about some of the more somatosensory balance training with weight shifting and stepping and those sorts of things. Use the Rating of Perceived Stability Scale. Do you know what that is? It’s like the new thing. It’s just like an RPE from one to 10, one being like, I could stand here all day.
Elise – @TheOncoPT (48:13.043)
Right?
Elise – @TheOncoPT (48:18.335)
Yeah.
Elise – @TheOncoPT (48:26.327)
No. No, I have not.
Kayla Gomes (48:32.981)
10 being like, if I don’t grab onto a wall right now, I’m gonna fall over. And the recommendation is with your balance exercises, it needs to be at least a six out of 10, meaning like they feel like they’re about to fall over. So it needs to be that intense. And yes, with the repetitions because we’re trying to improve neural circuits, right? And if I’m introducing vestibular training with these patients, like say they have a hypofunction on one side and I wanna get that a little bit more responsive.
Elise – @TheOncoPT (48:47.046)
Okay, I need to be doing that.
Right.
Elise – @TheOncoPT (49:02.728)
Mm-hmm.
Kayla Gomes (49:03.633)
you know, look at the CPG. It’s saying have the patients do it 12 minutes a day if it’s acute, 20 minutes a day if it’s chronic. Okay, all my patients are chronic. And I say to them, I’m like, if I tell you to do this 20 minutes a day, your neck’s gonna hurt and you’re never gonna come back. So you gotta tell them, break it up. You gotta break it up throughout the day. I start my patients at three times a day with.
Elise – @TheOncoPT (49:25.594)
Hahaha
Elise – @TheOncoPT (49:30.331)
Mm-hmm.
Kayla Gomes (49:31.273)
with these vestibular type exercises more or less Madison three one to two times a day, but I start vestibular stuff at least three times a day and Then if they are compliant with that then I’m like great do more That’s your reward do more of it Because if I tell them like, you know do it X number of times to get to that 20 minutes They’re like, I’m never gonna do that. Like let’s start small
Elise – @TheOncoPT (49:35.726)
Mm-hmm.
Elise – @TheOncoPT (49:43.566)
Hahaha
Elise – @TheOncoPT (49:53.794)
Right. I’ll get to like 10 on a good day kind of deal. Yeah, that’s I’ll get boom. I have homework from this episode y’all, which is like first of all, I need to get that rate of perceived stability because that sounds like a bomb tool. Yep.
Kayla Gomes (50:02.359)
Ha ha ha!
Kayla Gomes (50:08.029)
Yep, the RPS. And you can print it out, it’s beautiful. I have it laminated. Yep.
Elise – @TheOncoPT (50:13.002)
See, that’s what I need. That’s what I need to get for the clinic. And then you also mentioned the CPG as far as like, again, like look at what the research is showing us as far as dosing wise. What do we need to actually be doing with these patients? Love it. Love it. Kayla, where can people continue to learn from you and follow up and maybe even like follow you on social media?
Kayla Gomes (50:36.073)
My Twitter, oh my god I have to double check, I think it is NU as in Northeastern University underscore DPT. I’m on Twitter a lot, I’m also on LinkedIn. You could email me at KaylaGomesPT at gmail.com. Any of those. I like to chit chat about these things, I’m a big nerd. And I would love, truly I was like, okay, I’m a nerd and I wanted to be prepared so I’m like looking up articles before this interview.
And I’m like, oh my god, what if someone knows more about like chemotherapy and vestibulopathy than I do? Please tell me. Like if you’re like Kayla, yeah platinum agents, but also like this, uh, these chemotherapy agents have now shown all this. Please tell me, you know, there’s only so much we can all read. So I’d love to know if, yeah.
Elise – @TheOncoPT (51:17.934)
I’m gonna go.
Elise – @TheOncoPT (51:26.398)
Oh my gosh, for real, right? Yeah, yeah. Oh my God, Kayla, thank you so much for coming on the podcast. This is, it was, y’all, I tell you, like the first time I met Kayla, I think I may have like followed you or seen you afar on Twitter before this, but I met Kayla at the 2021, is that right? That feels a thousand years ago. Nope, it was 22.
Kayla Gomes (51:33.722)
Thanks for having me.
Kayla Gomes (51:42.145)
and social media.
Kayla Gomes (51:51.685)
Yeah, specialty cert.
Elise – @TheOncoPT (51:55.742)
It was 22 because 21 was virtual.
Kayla Gomes (51:59.617)
Oh, and they were celebrating the 2021 kids. Yes, us kids.
Elise – @TheOncoPT (52:02.41)
Yes. So we met in outright like the children, like we are the children. Right? Yes. So 2022, we are at the CSM, like a word pin, what have you ceremony for newly certified specialists and neuro alphabetically.
Kayla Gomes (52:07.545)
Yeah, the newly certified PTs at the time. Yeah, that was us.
Kayla Gomes (52:20.533)
Thanks.
Elise – @TheOncoPT (52:24.966)
starts with an N, and oncology starts with an O, so they’re right next to each other. And in the very back row of this one section, it was Jen Bernstein, Alexandra Hill and me, and we were all in this back row and we were giggling like little children. And Kayla was sitting in front of us.
Kayla Gomes (52:28.938)
Mm-hmm.
Kayla Gomes (52:41.801)
I’ve turned around.
I’m like, I love these people.
Elise – @TheOncoPT (52:44.974)
like you made a joke first of all and then we just like twitter back there and then basically Kayla was then nominated as an honorary Anko PT so that’s like that’s now she’s part of the Northo Anko PT coalition now I like that
Kayla Gomes (52:59.281)
I’m honored.
Noronco, Noronk, I don’t know.
Elise – @TheOncoPT (53:07.082)
I like that a lot. But yeah, Kayla is a wealth of information to follow on Twitter. She’s probably one of my favorite accounts to follow on Twitter because she’s always dropping… Girl, like you always have just this like these nuggets to take from. And I’m like, oh my God, I need to be writing this down. Like, I don’t even know how many of your tweets I’ve saved and bookmarks. I’m like, oh, I need to come back to that. Like, oh, shit, I need to learn that too.
Kayla Gomes (53:15.483)
Wow.
Kayla Gomes (53:25.859)
Oh, I appreciate that.
Kayla Gomes (53:31.295)
Say, what about you?
Elise – @TheOncoPT (53:34.422)
Now, now I’m a Nornco PT. I’m an honorary Nornco PT. Oh my God, Kayla, thank you so much. This was such a wonderful, very informative interview. And like I said, we’ve got a little more CIPN content coming up on the Onco PT podcast. Stay tuned. You don’t get it just yet, but you will very shortly. So again, Kayla, thank you so, so much. I really appreciate it.
Kayla Gomes (53:38.017)
Absolutely. Yeah, there you go.
Kayla Gomes (53:52.193)
coming. Good.
Kayla Gomes (54:00.417)
Thank you.