Cancer Rehab 2

cancer-related fatigue

“Distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning”

cancer fatigue

• Associated with surgery, chemotherapy, and radiation therapy

• Cumulative

• Reported by 85–100% of patients: number 1 complaint

• Does not improve with rest
  • “I am as tired when I wake up as when I went to sleep”

• Limits quality of life and ability to work

• Affects ability to concentrate, calculate, or remember: “chemo brain”

• “Can’t get through the day”

multifactoriallity of CRF

• Physical performance = Weakness or tiredness

• Mood = Depression, anxiety

• Motivation = Lack of initiative

• Cognition = Slowing of thought process, distraction, or memory deficits

• Social functions = Reduced ability to sustain social relationships

• Employment status

what may the individual feel with cancer fatigue

• Weak
• Worn out
• Heavy
• Slow
• Have no energy or “get-up-and-go”
• Wake up without feeling refreshed
• Exhausted
• Lazy
• Weary
• Tired
• Symptoms present every day or nearly every day.

what causes fatigue?

• Cancer
• Cancer treatments (surgery, chemo, radiation)
• Anemia
• Insomnia/sleep disturbance
• Nutrition
• Depression and anxiety
• Medications
• Too much activity
• Lack of exercise
• Hormones
• Difficulty breathing
• Cardiac issues
• Infection
• Pain
• Stress
• Dehydration
• Weight loss
• Other medical conditions

screening for fatigue

• Numeric rating scale (0–10)
  • 0 equals no fatigue and 10 equals worst fatigue imaginable
  • Mild fatigue: 1–3
  • Moderate fatigue: 4–6
  • Severe fatigue: above 7

• Research shows that patients with scores above 7 have significant decreased functioning

outcome measures for cancer fatigue

• FACT: Functional Assessment of Cancer Therapy
• BFI: Brief Fatigue Inventory
• Linear Analog Scale
• Piper Fatigue Scale
• SF-36
• POMS (Profile of Mood States) Fatigue Subscale

how is fatigue treated?

• patient education

• energy conservation

• no-pharmologic

• pharmologic

NCCN guidelines

• “Activity enhancement”
• Across all stages of survivorship
• Avoid inactivity

what can we address with cancer fatigue?

• Pain
• Inactivity
• Musculoskeletal comorbidities
• Emotional distress regarding inability to get through the day

Treatment of Cancer Fatigue

• Close monitoring of blood values
• Light aerobics
• Functional activities
• Energy conservation
• Sleep hygiene education
• Home exercise programs

blood values

slide 77 in cancer rehab 1

energy conservaiton “the P’s”

• Pacing = Balancing activity with rest
• Planning = Plan ahead, balancing hard activities with easier tasks
• Posture = Sit down to work if possible, When carrying, hold object close to body
• “Put it” (i.e., organization) = Move frequently used items closer

mode of exercise for cancer fatigue

• locale

• type

locale

• Home-based/unsupervised
• Institution-based/supervised

type of exercised

• Walking programs
• “Asphalt’s free...”
• Stationary cycling
• Resistance training
• “Preferred exercise”

intensity of exercise

• Methods for monitoring
  • Heart rate
  • Predicted O2 uptake
  • Perceived effort: Borg Scale—“talk test”
  • Self-paced intensity

• Overall time spent exercising? goal = 30 min

exercise prescription

Should be individualized according to:
• Pretreatment aerobic fitness (and preferences)
• Medical comorbidities
• Response to treatment
• Immediate or persistent negative effects of treatment
• Blood counts
• Peripheral neuropathy/balance deficits
• Type
• Frequency
• Duration
• Intensity

how should one prescribe resistance training?

start slow and progress slowly

how would one measure exercise intensity?

using the Borg test andt talk test, heart rate

Caution Performing Exercise With Any of the Following

• Bone metastases (cancer spread to the bone)

• Thrombocytopenia (low platelets)

• Anemia (low red blood cells)

• Neutropenia (low white cells)
  • Avoid environments where there is risk of exposure to infectious diseases (i.e., public swimming pools, crowded gyms)

how much exercise is need to promote and maintain health in persons affected by cancer?

• Thirty minutes of moderate intensity aerobic exercise 5 days each week

• Moderate intensity resistive exercise on 2–3 days each week
  • Three sets of 10–15 repetitions for 6–8 muscle groups with a 1–2 minute rest between sets or exercises
  • Start low, progress slowly

• Flexibility exercises

• Balance exercises

fibrosis

• radiation

• tissue fibrosis

mechanism of radiation fibrosis

induction of apoptosis, or cell death, via free radical-mediated DNA damage
• Activates coagulation system, inflammation, epithelial regeneration, tissue remodeling

phases of radiation fibrosis

• Pre-fibrotic phase: chronic inflammation
• Organized fibrosis phase: high density of myofibroblasts
• Fibroatrophic phase: retractile fibrosis and loss of parenchymal cells

where would you do manual therapy when it comes to radiation fibrosis?

in areas outside of readiated field

radiation short-term effects

• soft tissue: Erythema, inflammation, decreased sweat and hair growth, skin breakdown possible (wet desquamation)

• GI tract: Anorexia, nausea and vomiting, diarrhea, mouth
  sores, esophagitis, mucositis, incontinence, fecal urgency

• Bone marrow: Myelosuppression (decreased blood counts, bone marrow failure)

• Global: (local)Edema

• Global: Fatigue

long term effects of radiation

• skin: Fibrosis, change in pigmentation, delayed healing, necrosis, radiation recall, telangiectasia

• global: long termm fatigue

• muscle and soft tissue: Fibrosis, diminished blood flow through capillaries

Common Radiation Associated Clinical Signs/Syndromes

• Neck extensor weakness
• Shoulder pain and dysfunction
• Cervical dystonia
• Trismus
• L’hermitte’s sign

L’hermitte’s sign

Tissue Fibrosis and Scars

• Associated with surgical incisions, radiation, and lymphedema

treatent for tissue fibrosis

• Myofascial techniques

• Compression with garments/bandaging

• Compression with silicone elastomers

• Functional taping for mobilization with patient movement

• Multi-planar flexibility exercises long-term
  • Shoulder/trunk AROM
  • C-spine AROM included if XRT supraclavicular
  • Attention to scalene flexibility REQUIRED

• Do not try to “break up” adherent tissues!

Survivors experience from breast cancer impairments such as

• Pain
• Decreased strength
• Decreased tissue flexibility
• Lymphedema

asssociated MSK diagnoses with breast cancer

• Rotator cuff disease
• Adhesive capsulitis
• Axillary web syndrome
• Myofascial dysfunction
• Soft tissue fibrosis
• Lymphedema
• Malignant lymphedema
• Deep vein thrombosis
• Post-mastectomy syndrome
• Brachial and cervical plexopathy
• Neuropathy
• Long thoracic nerve palsy
• Cancer recurrence

surgery for breast cancer

• lumpectomy

• masectomy

lumpectomy

the malignacy and around the area is taken out

masectomy

the breast tissue is taken

• radical: entire breast, lymph, chest wall

• modified: breast nadd lymph

• simple: just breast tissue

breast reconstruction

• implant

• aoutologus

• combo

breast implant

Two-step procedure
• Tissue expander at time of mastectomy placed beneath pectoralis major
• Injections of saline to stretch skin every 1–2 weeks
• Expansion remains during XRT
• Expander replaced by permanent implant in 3–6 months post-XRT

saline vs. silicone

indications for breast implant

• Patient preference
• Patient too thin—insufficient tissue for autologous reconstruction
• Heavy smoker

disadvantages for breadt implant

• Do not change size if gain/lose weight
• Cold in cold environment
• Usually require replacement within 10 years

autologus

• TRAM

• DIEP

• SIEA

TRAM

Transverse rectus abdominis myocutaneous flap
• Pedicled flap
• Free flap
• Muscle sparing

DIEP

Deep inferior epigastric perforator free flap

SIEA

Superficial inferior epigastric artery free flap

combo

use latissimus dorsi muscle

• would cause difficulyt opening doors

sential lymph node biopsy

put tracer in

• look to see where it

• accumulates

• biopsy 3-4

axillary lymph node disection

evidence of metastisis, harvests more lymph nodes

what is mmoe likely cause for lymhedma

• axillary lymph node disection

• BMI > 30

• radiation

Altered Resting Scapular Alignment

Protective posturing due to:
• Pain
• Fear
Reduced tissue flexibility —> Altered alignment

Pectoralis Major Muscle Dysfunction

Tightness

• Overhead flexion = Increased tension

• Extension/ER and abduction/ER = Increased tension

• Flexion to 90 degrees = Decreased tension

• Biomechanics changed by expansion

Pectoralis Minor Muscle Dysfunction

Short pectoralis minor
• Healthy individuals
• Reduced scapular posterior tilt at end range of arm elevation
• More scapular internal rotation at early and mid range of arm elevation

Lymphedema

• Abnormal accumulation of fluid leads to increased weight of arm

• Increased weight of arm results in greater load being applied to shoulder muscles
  • Fatigue
  • Lead to tension overload and rotator cuff disease

Axillary Web Syndrome

loss or AROM in shoulder

• feeling a pull sensation dwon medial arm, can b=go to elbow or thumb

cause of Axillary Web Syndrome

• inflammation of neurovascular bundle after nodal dissection

• blood vessels?

• Peripheral nerve (usually median nerve)?

• Lymphatic vessels?

• any of the above

treatment axiallary web sydrome

• Gentle myofascial work over cording
• Gentle trunk and UE flexibility exercises
• Gentle rib mobility
• Nerve gliding exercise
• Gentle moist heat: caution! The patient is at risk for lymphedema
• Do not “break up” the cords—inflamed structures are already irritated and it is counterproductive

imparments after chemoradiation adn surgery for head and neck cancer

• C spine AROM and pain
• Trismus
• Postural dysfunction
• Shoulder dysfunction—spinal accessory nerve palsy
• Cancer-related fatigue
• Lymphedema
• Swallowing dysfunction

neck dissection types

• radial neck dissection

• modifed radial neck

• slective

Radical neck dissection

removal of cervical level I–V lymph nodes, spinal accessory nerve (SAN), internal jugular vein (IJV), and sternocleidomastoid (SCM)

Modified radical neck dissection

Removal of cervical level I–V lymph nodes but preserves at least one of the following structures: SAN, IJV, and SCM

Selective neck dissection

One or more cervical lymph node levels removed; most nodes are preserved

trapezius muscle

• active shoulder abduction difficulty

• scapular flip sign

Graft vs Host Disease (GVHD)

• Complication of allogenic stem cell transplantation
  • With allogeneic transplants (between two individuals), white blood cells from the donor (the graft) identify cells in the patient’s body (the host) as foreign and attack them

• Primary treatment: high-dose steroids

acute GVHD

• Skin
  • Erythematous rash on palms and soles
  • Bullae formation

• GI
  • Diarrhea
  • Abdominal pain
  • Nausea/vomiting

• Hepatic
  • Jaundice
  • Raised liver enzymes

chronic GVHD

• Skin
  • Lichen planus
  • Sclerodermatous changes

• Muscle, fascia, joints
  • Fasciitis
  • Joint stiffness/contractures
  • Steroid myopathy

• Lung
  • Bronchiolitis obliterans (bronchioles are compressed by scar tissue or inflammation)

• GI
  • Stenosis of esophagus

PT treatment for GVHD

• contractures

• steroid myopathy

Treatment of joint contractures

• Stretching
• Thermal modalities (paraffin or moist hot pack)
• Splinting
• Static/dynamic

Steroid myopathy

• Exercise
• Transfer and balance training

other impariment

• Bone health
• Osteoporosis
• Pelvic floor dysfunction
• Lymphedema

what can learn From patients facing life-threatening illnesses

• What really matters?
• Living each day in the present, not in the future or the past
• Learning how to place themselves first
• Learning how to say what they really need