Oncology Rehabilitation (Guest - Jill Wing)

What will bone marrow suppression cause in regard to lab values?

-anemia

-thrombocytopenia

-leukopenia / neutropenia

What are the normal lab values for hemoglobin? What is low considered?

male 14-18

females 12-16

anemia = low RBC

What are s&s of anemia? What are PT implications?

s&s: fatigue, irritability, lightheadedness, HA, loss of concentration, pallor, SOB, lower exercise tolerance

PT: monitor vitals, lab values, fatigue levels

What is the normal lab value for platelets? What is low considered?

normal 150,000 to 400,000

low = thrombocytopenia

What are s&s of thrombocytopenia? What are PT implications?

s&s = bruising, bleeding, petechia

PT: monitor lab values, fall precautions, focus on functional mobility (no strenuous resistance training)

What is petechia?

broken capillaries on skin

What is the normal lab value for WBC? What is low WBC termed?

-normal is 3,500 to 10,500

-low WBC = leukopenia

What are s&s of leukopenia / neutropenia? what are PT implications?

s&s = frequent infections, fever, throat & mouth sores

PT implications = reverse protective isolation, creative treatment interventions (exercise in gym without anyone around, lots of cleaning)

What does reverse protective isolation mean?

wearing gloves & mask in order to protect the PATIENT rather than protect self from patient

What are the WBC count exercise guidelines?

<5k = no exercise

>5k = light exercise, progress to resistance

What are the hemoglobin lab value guidelines for exercise?

<7 = no exercise

7.5 - 10 = light exercise, functional mobility

>10 = resistive exercise permitted

What are the guidelines for exercise in regard to platelet count?

<20k = no exercise

20-30k = light exercise, AROM, walking

30-50k = moderate exercise, aquatics, stationary bike

50-150k = progressive resistance exercise, swimming, bike

>150k = unrestricted normal activity

What value of INR will permit no exercise to be done?

>4.0

What is the definition and sx of DVT?

clot of cellular material bound to fibrin, located in deep veins

s&s = edema, erythema, pain

What is the definition and sx of PE?

blood clot which obstructs the pulmonary artery / vein

s&s = dyspnea, low O2, tachycardia, chest pain

What are treatments for blood clots? Why are they more likely in cancer pts?

tx: anticoagulants, IVC filter (for LEs)

higher incidence in oncology pts due to tumor enzymes causing them or due to trauma from cancer treatment

What are PT implications for blood clots in oncology pts?

-be aware of them during treatment

-monitor appropriate blood values

-monitor O2 and HR closely

T or F: Anticoagulants are used to dissolve the blood clot to treat a DVT or PE

False; anticoagulants are used for treatment, but they make the blood thinner so that blood can go around the clot

T or F: Chemotherapy may be a primary, adjuvant, or palliative cancer treatment

True

What is the difference between primary, adjuvant, and palliative treatments for cancer?

primary = the only treatment the patient is receiving

adjuvant = in coordination with another treatment, such as chemo + surgery

palliative = treatment without the intention to cure, but rather reduce pain and reduce progression of disease progress

What does chemo do? How is it given?

destroys all rapidly dividing cells (doesn't target cancer cells)

oral, IV, wafers, Ommaya reservoir (placed in brain for a neural diagnosis)

What are PT implications for chemo?

-bone marrow suppression

-neuropathy (bc myelin are rapidly dividing cells that chemo will destroy)

-cardiac toxicity

-fatigue

-cognitive impairments

T or F: Radiation therapy can be a primary and adjuvant treatment, and is not a palliative treatment

False; it can be all 3 types of treatment

What are the types of radiation therapy?

-external beam RT

-stereotactic RT

-IMRT (intensity modulated radiation therapy which are beams that converge at a point)

What are PT implications for RT?

-fatigue

-acute burns/blistering

-radiation

-fibrosis / necrosis (brain, lungs, trismus)

What is trismus? What causes this?

Limited opening of the mouth / jaw; caused by fibrosis secondary to radiation of the neck musculature

How does impaired cognition from cancer treatments relate to PT implications?

-safety awareness

-orientation

-ability to follow commands

-memory

T or F: Oncological patients with a neuro-based cancer diagnosis are the only type of patients to have cognitive problems

False; cancer tx in general will affect cognition

What are the PT implications of hydrocephalus resulting from cancer tx?

-avoid Valsalva maneuver

-no excessive bending or heavy lifting

-HOB to 30deg or higher

-monitor headaches

-nausea

-dizziness

-increased BP

What are PT implications for neuropathy and radiculopathy resulting from cancer tx?

-assess and monitor sensation to light touch

-proprioception

-balance

-coordination

What are the PT implications for pts with bony metastises?

-WB status

-ROM restrictions

-spinal precautions

What are the PT implications for pts with steroid myopathy?

-proximal muscle weakness (like hip)

-monitoring changing in strength

What are the PT implications for pt with prolonged bed rest / deconditioning?

-monitor vitals throughout treatment

-loss of BMD

How can a doctor differentiate if a cancer in the brain is brain cancer, or a metastasis from breast cancer?

doctor will test the cancer cell and determine if it is a brain cell OR if it is a breast cell

T or F: Primary bone tumors occur commonly in adults

False; RARE in adults

Who is affected most by primary bone tumors?

kids

What are s&s of bone tumors?

-pain

-swelling

-palpable mass

-sensory and/or motor changes

-functional changes

-gait disturbances

-fx

-systemic sx

T or F: An adult with primary bone tumor has a worse prognosis than a kid with a primary bone tumor

True

What are the types of primary bone tumors?

-osteosarcoma

-chondrosarcoma

-multiple myeloma (paired with blood bone disorder)

T or F: Metastatic bone disease is more common than primary bone tumors

True

What are osteolytic metastases? What cancers likely cause these?

cancer cells that cause bone destruction

-renal cancer

-lung cancer (non small cell)

-melanoma

-thyroid cancer

What are osteoblastic metastases? What cancers likely cause these?

cancer cells that cause bone formation

-prostate cancer

-lung cancer (small cell)

T or F: Small cell lung cancer may cause osteoblastic metastases

True

T or F: Non small cell lung cancer may cause osteolytic mets

True

T or F: It is possible for a patient to have a mixed type of osteoblastic and osteolytic metastases

True

Which type of cancer is likely to cause a mixed type of bone metastases types, both osteolytic and osteoblastic?

breast cancer

How are bone mets diagnosed? What do they show

-imaging

-biopsy

-blood test (increased alkaline phosphatase, increased calcium)

What is the treatment for bone tumors?

-surgery

-chemo

-RT

-protected WB

-pain management

-biphonates

If a pt with a bone tumor gets surgery, what will be done to provide stabilization?

-possibly have rods/screws added for prosthetic stabilization

-may get a partial or total joint replacement

What is a sacrectomy?

-partial or complete resection of sacrum at the SI joint (possible resection of S3,2,1)

-spino-pelvic reconstruction (sitting precautions!)

What is an internal hemi pelvectomy?

resection of portion of hemipelvis and proximal femur with reconstruction

What is an external hemi pelvectomy?

amputation of entire LE and hemipelvis with disarticulation of SI joint and pubic symphysis

What is a tikhoff-lindberg resection?

resection of distal clavicle, proximal humerus, scapula, muscle transfer & skeletal reconstruction

-preservation of the neurovascular pedicle of the arm

-functional elbow and hand

What is a forequarter amputation?

-excision of entire UE, clavicle, and scapula

-UE equivalent of external hemipelvectomy

-affects balance and posture

What is a Van Ness Rotationplasty? What are indications for it?

-amputation of limb at distal femur, with rotation and re-insertion of residual limb

-indications: tumors of distal femur, pt age

With a Van Ness rotationplasty, which ankle motions become knee flex/ext?

DF = knee flexion

PF = knee extension

What are rehab implications for any type of ortho-based cancer surgical procedures?

-pain control

-WB and activity restrictions

-progressive ROM & strengthening

-functional and gait training

-neuro muscular re-ed

-ADLs

What is the second leading cause of cancer deaths?

breast cancer

What is the most common cancer in women?

breast cancer

What are clinical s&s of breast cancer?

-lump

-puckering/dimpling

-rough / dry scaly skin

-erythema or local rash

-nipple discharge

-nipple retraction

-lymphadenopathy

What are the types of breast cancer?

-ductal

-lobular

-inflammatory

Describe ductal breast cancer, specifically its origin and types. What percentage of breast cancers is it?

-origin = milk ducts

-types = in situ and invasive (invades surrounding tissue)

-85% of all breast cancers

Describe lobular breast cancer, specifically its origin and types. What percentage of breast cancers is it?

-origin = milk lobules

-types = in situ and invasive

-10-15% of all breast cancers

How is a breast cancer diagnosis made?

-self breast exam

-clinical examination

-imaging techniques (mammogram, US)

-biopsy (needle, open)

How is breast cancer staged?

TNM

T = tumor size

N = nodes affected

M = mets present or not (0 or 1)

What is a sentinel node biopsy?

-test with injection of radioisotope blue dye in which sentinel nodes are identified and biopsied

-biopsy areas where the dye goes until doc finds the lymph node in which there are no cancer cells present

What is an axillary node dissection and its purpose? What is the risk

-removal of lymph nodes in the axilla

-prevents further spread of disease

-risk = lymphedema increased risk

T or F: A pt with breast cancer can get lymphedema without actually having any lymph nodes removed

True -- can get lymphedema just from radiation and chemo

What are the types of breast salvage surgery? What are the types of breast removal surgeries?

breast salvage:

--lumpectomy

--partial mastectomy

breast removal

--total mastectomy

--modified radical mastectomy

--radical mastectomy

What are the breast cancer treatment options?

-surgery

-RT

-chemo

-hormone therapy

What encompasses hormone therapy for breast cancer tx?

-anti-estrogen

-anti-progesterone

-herceptin

What is a total mastectomy?

The removal of the full breast tissue

What is a modified radical mastectomy?

entire breast tissue and axillary lymph nodes

musculature is NOT taken out

What is a radical mastectomy?

breast, axillary lymph nodes pectorals major & minor muscles removed

What are the two types of reconstructive surgery after breast cancer surgery?

-tissue expander & implant

-autologus grats

Describe the tissue expander route of reconstructive breast cancer surgery

-temporary prosthesis that goes under the pec major

-expands with saline for 4-8 weeks

-eventually replaced with a permanent implant

-alloderm graft or latissimus flap

What is an alloderm graft?

type of graft used after a tissue expander post for reconstructive breast surgery

-actual tissue matrix

-goes under the inferior border to breast for extra support

What is an latissimus flap? What is the indication for it?

-type of procedure used after tissue expander for reconstructive breast surgery

-transfer of overlying fat, skin and part of the Lat muscle to ipsilateral chest wall

-used if there is decreased viable skin to create breast tissue

-not a great option as it creates adherent scar tissue on the back

What is a pedicle TRAM? Describe it and what it stands for

-type of autologus graft used for reconstructive breast surgery

-TRAM = transverse rectus abdominal myocutaneous

-transfer of rectus abdominis muscle, blood supply, fat and skin to the mastectomy site

-one end remains attached and the other end tunneled thru abdomen to mastectomy site

-not good for obese or smokers due to decreased blood supply

What are implications for PT after a pedicle TRAM?

core instability problems

What is a free/muscle sparing TRAM?

-type of autologus graft used for reconstructive breast surgery

-complete transfer of skin, muscle, and blood vessels (from one area) to mastectomy site with reconnection to blood supply

-muscle sparing = optimal to remove least amount of muscle fibers

What is DIEP TRAM? Describe it

-deep inferior epigastric perforators (flap blood supply) transverse rectus abdominal myocutaneous

-donor tissue is removal of abdominal skin, fat, and blood supply with rectus muscle being spared

-blood vessels reconnected

What describes the procedure in which the large blood vessel in the abdomen along with the fat and skin is disconnected from the belly and re-attached to chest?

DIEP TRAM

What are risk factors for lymphedema? What is tx?

risk factors

--axillary lymph node dissection

--radiation to the axilla / breast

tx = complete decongestive therapy

--MLD

--compression

--self care (exercise and skin care)

What are rehab implications for pts with breast cancer?

-activity restrictions / guidelines

-progressive ROM / strengthening

-postural re-ed (core stab, scap stab, bra fitting)

-manual therapy (lymphedema, manual on scars)

What are common sites of breast cancer metastatic disease?

regionally: axillary lymph nodes

distant: bone, brain, lung, pleura

Breast cancer mets may develop during what time period after the primary cancer tx?

could be after 10+ years

What are PT implications for pts who had a previous breast cancer diagnosis, who may be at risk of metastatic disease?

-WB status

-pulmonary status

-safety awareness

-other neuro sx

-regularly testing strength

-sensation

-chemo / RT side effects

T or F: The most common sites of breast cancer metastatic disease is brain, lung, thyroid (BLT)

False; bone, brain, lung, pleura

What is cording and how is it treated?

fibrous bundling due to surgery, radiation, chemo; causes restricted ROM as well as n&t

tx: manual therapy and ROM

Why might a cancer pt have more pain at night?

At night, there is reabsorption of fluid in the tumor, thus causing more pain

What is the 5 year survival rate with primary brain tumors?

HIGHLY variable

6 - 92%

What are clinical signs of primary brain tumors?

-headache worse in AM (due to increased pressure from fluid reabsorption)

-fatigue

-seizures

-personality changes

-n&v

-vision changes

-pressure near tumor site

Describe the grades or primary brain tumors in regard to their growth rate and classification

grade 1-2

-slow growth rate

-low grade astroocytoma

-(so slow that pt may not realize deficits until it has increased pressure on skull)

grade 3

-fast growth rate

-anaplastic astrocytoma

grade4

-very fast growth

-glioblastoma multiform (GBM)

Brain metastases account for what percentage of all brain tumors?

30%

What are the cancers that cause brain mets more often? What is the survival rate with a brain met?

lung, breast, melanoma, kidney

3-6mo survival

What is treatment for brain tumors?

-surgery

--stereotactic surgery (small needle)

--craniotomy (resection of skull)

--shunt placement (bypass CSF blockage for sx management of high ICP)

-RT

--external beam (one beam @ one point)

--whole brain (wider beam with wider dosage, thus cog deficits and memory issues)

-chemo

-meds

What are meds that may be taken for brain tumors? What is their purpose and what are common side effects of these meds as a whole?

-anticonvulsants (Dilantin) for anti-seizures

-steroids (Decadron) to decrease cerebral edema, alleviate sx for 1-2 days, gradually tapered

-common side effects:

--irratability

--insomnia

--fluid retention

--hypokalemia, hypermatremia, hyperglycemia

-osteoporosis

-MYOPATHY!!

What at PT implications for pts with a brain tumor? What are red flags?

-assess and monitor sensation, proprioception, strength, coordination, cognition / personality changes, functional mobility

-VITAL SIGNS and monitor for seizures

-Pt education for 30deg when supine and avoid bending forward

RED FLAGS

-increased ICP --> elevated BP, n&v, headache

What is the leading cause of cancer death in both men & women?

lung cancer