Cancer Rehab

what is cancer rehabilitation?

process to restoring and maintaining highest possible level of functioning, independence, and QOL to cancer patients and survivors

what are the objectives for rehabilitation of cancer survivors?

psychosocial support, optimization of physical functioning, vocational counseling, optimization of social functioning

what are the categories of cancer prevention?

preventative, restorative, supportive, palliative

what specialist certification can you obtain if interested in cancer rehab PT?

oncology

functional problems are ____ among outpatients with cancer and are ____ documented by oncology cminicians

Prevalent, rarely

what realms make up cancer rehabilitation?

Physicians, psychologists, PTs, OTs, speech therapists, nutritionists, social workers, nurses

at what stage is cancer rehabilitation appropriate?

Throughout the cancer journey

PT’s role in cancer rehab

examine, diagnose, prevent/treat conditions that limit the body’s ability to move/function, develop plans of care

what history is pertinent to cancer

when/how was it diagnosed, type/grade/stage, health status at diagnosis, cancer treatment received or planned, diagnostic tests, is primary treatment completed, metastatic disease

common impairments in cancer patients

pain (joint, msk, neuropathic), fatigue, weakness, deconditioning

causes of concern or red flags

compression of neurologic tissue, cardiac ventricular function, bone health, anemia/neutropenia/thrombocytopenia

common site of metastasis in breast, lung, and prostate cancer

bone

what precautions must be taken if bony-metastasis involves more than 50% of the cortex?

no exercises, touch down NWB, use crutches/walker, active ROM exercises w/ no twisting

what precautions must be taken if bony-metastasis involves 25-50% of the cortex?

no stretching, PWB, light aerobic activity avoiding lifting/straining

typical no exercise cutoff for anemia, neutropenia, thrombocytopenia

below 25% hematocrit, below 8 g/dl hemoglobin, below 5.0 10^9 WBC and fever, below 20k/uL platelets

what are the categories of oncologic emergencies?

structural/obstructive, metabolic, hematologic

examples of structural oncologic emergencies

spinal corn compression, malignant pericardial perfusion, superior vena cava syndrome

what most commonly causes acute spinal cord compression

extradural mass from vertebral metastasis (early recognition is critical)

what is the presentation of acute spinal cord compression?

worsening back pain, night pain, change in neurological status

overall prognosis for acute spinal cord compression

medan survival is 3-6 months, one year survival rate is 30%, pre-treatment ambulatory status is key factor

treatment for acute SC compression

high dose steroids, focused radiotherapy, surgical resection/stabilization

most common clinical features of superior vena cava syndrome

facial edema, distended neck veins, collateral veins of chest, SOB, arm edema

treatment for superior vena cava syndrome

high dose steroids, intravascular stenting, localized radiotherapy (not immediately life threatening)

examples of metabolic oncologic emergencies

Hypercalcemia, tumor lysis syndrome

examples of hematologic oncologic emergencies

neutropenic fever, venous thromboembolisms (DVT or PE)

how does risk for venous thromboembolism change in individuals with cancer?

4-7 times more likely

what can be used to assess DVT risk?

Wells rule

how prevalent is cancer pain?

30-40% overall, up to 90% with advanced disease

what are the pathophysiological categories of cancer pain?

somatic, visceral, neuropathic

well localized pain caused by activation of peripheral nociceptors, w/o injury to the nerve or CNS, sharp and reproduced by movement

somatic pain

diffuse and difficult to localize pain that is often referred to a superficial structure, caused by activation of nociceptors of thoracic, pelvic, or abdominal viscera, “vague ache”

visceral pain

burning/stabbing/shooting pain due to damage or disease affecting the somatosensory NS, associated w/ dysesthesias or allodynia

neuropathic pain

treatment options fro cancer pain

pharmocologics, alternative modalities,, CBT, physical agents

indications for the use of physical agents

part of treatment during or immediately post cancer treatment, for MSK pain in a cancer survivor

contraindications to superficial heat/cold that are importan t in the cancer population

over dysvascular tissue from radiation therapy, impaired sensation, impaired mental status, directly over tumor

contraindications/precautions for E-stim use

over carotid sinus/implanted device, thrombosis, altered skin resistance, decreased sensation, tissue at risk of hemorrhage, skin irritation, pregnancy (get physician clearance 1st in cancer population)

contraindications/precautions for ultrasound use

malignancy, thrombosis, breast implants, indwelling stimulators, pregnancy, CNS tissue, fractures, acute inflammation, growing epiphysis (usually contraindicated in cancer poplation)

what should be involved in screening for the appropriateness of physical agents in patients with cancer?

cancer history, last oncologist follow up, MD clearance, treatment effects, comorbidities/PMH

Is ultrasound typically used in the cancer population? why/why not?

not in the region of cancer or possible metastatic spread

set od symptoms caused by damage to nerves that can occur with antineoplastic agent use

chemotherapy induced peripheral neuropathy (CIPN)

symptoms of CIPN

may occur 24 hours after infusion and last weeks/months/indefinitely, severity is dose/duration dependent, may be sensory/motor/autonomic

primary treatment for CIPN

dose reduction or shift in type of chemo

CIPN treatment

neuromuscular e-stim, education, falls prevention, therapeutic exercises to increase blood flow to periphery, compression, desensitization

Persistent, distressing, subjective sense of physical, emotional, or cognitive tiredness related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning

cancer related fatigue (CRF)

what is the number 1 cancer complaint that is reported by 85-100% of patients

cancer related fatigue

qualities of CRF

cumulative, doesn’t improve w/ rest, limits QOL and ability to work, affects ability to concentrate, “can’t get through day”

what multifactorial areas make up CRF?

physicla, performance, mood, motivation, cognition, social functions, employment status

how can CRF be screened?

numeric rating scale (0-10)

how is CRF treated?

patient education, energy conservation, non-pharmacologic, pharmacologic

inactivity should be ______ in individuals with cancer

avoided

what can PT address to help with CRF?

pain, inactivity, MSK comorbidities, emotional distress

what has been shown to be the most effective non-pharmacologic intervention for CRF?

exercise

what principles make up energy conservation?

pacing, planning, posture, “put it” (organize frequently used items closer together)

what mode of exercise provided the largest treatment effect in individuals with CRF?

combination of aerobic and resistance training

how should exercise be dosed for individuals with CRF?

start low and progress slowly, ideal is 30 minutes 5x per week

how can moderate intensity easily be measured?

talk test (can have a conversation but can’t sing)

conditions that require caution when performing exercise

bone metastases, thrombocytopenia, anemia, neutropenia

what is the mechanism of radiation fibrosis?

induction of apoptosis via free radical mediated cell damage

phases of radiation fibrosis

pre-fibrotic phase, organized fibrosis phase, fibroatrophic phase

common radiation associated clinical signs/syndromes

neck extensor weakness, shoulder pain/dysfunction, cervical dystonia, trismus, L’hermitte’s sign

treatment for tissue fibrosis and scars

gentle myofascial techniques, compression, fucntional taping, multi-planar flexibility exercises (do not try to break-up adherant tissues or use aggressive manual therapies/heat)

2 primary surgeries for individuals with breast cancer

lumpectomy (removes malignancy and small part of the rim), masectomy

options for breast reconstruction

implant, autologous, autologous/implant combination

surgery that may be done to look for metastatic disease

Sentinel lymph node biopsy

performed if metastatic disease if found in a sentinel lymph node biopsy

axillary lymph node dissection

should you push through the pain with exercise in people post radiation?

no

affects of breats cancer on the shoulder

protective posturing due to pain/fear→ greater asymmetry of shoulder girdles (reduced tissue flexibility and altered alignment)

effects of pectoralis major dysfunction (biomechanics changed by expansion)

increased tension in overhead flexion and extension and abduction ER, decreased tension w/ flexion to 90

effects of pectoralis minor muscle dysfucntion

reduced scapular posterior tilt at end range elevation, more scapular IR at early/mid range elevation

abnormal accumulation of fluids that leads to increased weight of the arm

lymphedema

cord in the armpit, patients demonstrate loss of shoulder AROM and pulling down the medial arm that can extend to the elbow or base of thumb

axillary web syndrome

treatment for axillary web syndrome

gentle myofascial work, gentle trunk and UE flexibility exercises, rib mobility, nerve gildes, gentle moist heat (do not break up cords)

possible impairments post head and neck cancer treatment

C-spine/shoulder dysfunction, trismus, postural dysfunction, spinal accessory nerve palsy, CRF, lymphedema, swallowing dysfunction

effect of spinal accessory nerve palsy

weak trapezius muscle (scapular flip sign)

complication of allogenic stem cell transplantation where WBCs from the donor identify cells in the pts body as foreign and attack them

graft vs host disease (GVHD)

primary treatment for GVHD

high dose steroids

PT interventions for GVHD

treatment of joint contractures, steroid myopathy treatment