Oncology for Rehabilitation

What are the primary goals in oncology rehabilitation?

• Improve quality of life

• Maintain independence

• Reduce side effects of cancer/treatments

• Maintain and gain physical/mental wellness throughout survivorship

What are the therapist roles in oncology rehabilitation?

• Address the following:

  • Pain, swelling, weakness, fatigue, ROM, balance

  • Neuropathy, lymphedema, axillary cording, radiation fibrosis

  • Functional independence

  • Pre-Op/Tx baseline assessments

  • Swallowing, chewing food

  • Multitasking, memory, safety awareness, medication management

  • Body image and general coping

  • DME recommendation

Melphalan

Medication that requires pt to chew ice 30 minutes prior to chemo infusion, during, and 2 hours after completion

Busulfan

Medication that crosses the blood brain barrier and causes seizures or seizure like symptoms. You are unable to work with pt during infusion. Pharmacokinetic studies drawn at specific times are required.

Thiotepa

Medication that seeps out of skin, requiring pt to shower at least 4 times a day. Encourage pt to wear hospital provided clothing. PPE considerations

Ribavirin

Medication that is Aerosol only: do not enter room when medication is running. Patient must remain in room for duration of treatment then use PPE

Etoposide

Medication that can cause hypotension if administered too quickly

Benadryl

Medication that is commonly given before infusion. Patient may become sleepy or have affected balance.

Corticosteroids

Medication that increases risk of muscle atrophy (especially proximally & avascular necrosis)

Midodrine

• Medication that is used to manage orthostatic hypotension

• Must be cleared for PT

  • Therapists must see patient within 1-59 minutes after the pt has taken med

• Takes about 30-40 minutes to take effect

• Keep HOB > 30 deg

If a patient is taking _________ and OT/PT is on the schedule, therapist must see the patient 1-59 minutes after the medication is given.

Midodrine

Ommaya Reservoir

• Soft plastic dome the size of a quarter

• Treats CNS cancers

• Prevents CNS cancers

• Treat Hydrocephalus

• Drain/test CSF

• Usually never removed

Considerations for the Ommaya Reservoir

For 6 weeks…

• No heavy contact to head

• No contact sports/high intensity activity

• Gentle ADLs with head grooming

Clinical manifestations of Axillary Web Syndrome

• Web of thick, rope-like structures called “cords”

  • May not be visible/felt but pt will report “pain and tightness”

• Possible result of Sentinel Lymph Node Biopsy or Axillary Lymph Node Dissection (more common)

• Caused by trauma to the connective tissue that encases bundles of blood vessels, lymph vessels, and nerves.

What does Axillary Web Syndrome result in?

• Inflammation, scarring, and hardening of tissue

  • Decrease in ROM and function

  • Increase in pain

Therapist roles for Axillary Web Syndrome

• Education

• PROM/AAROM/AROM (UE, trunk)

• Nerve glides

• Manual therapy (may hear popping)

  • Myofascial release

  • Soft tissue mobilizations

  • Cord manipulation

  • Joint mobilizations

  • Scraping

• Moist heat (avoid if patient has lymphedema)

• Specialized lymphedema therapy

• Anti-inflammatory medications

Cancer related fatigue

Feeling of debilitating tiredness or total lack of energy that lasts for days, weeks, or moths; more severe, lasts longer, limits ADLs/IADLs

T/F: You can fix Cancer Related Fatigue by sleeping

False; this will make it worse

Etiological factors of Cancer Related Fatigue

• Cancer & cancer treatment (medications and/or radiation, etc)

• Anemia

• Poor duration or quality of sleep

• Inactivity

• Poor nutrition

• Low mood

Clinical manifestations of Cancer Related Fatigue

• Pain

• Fatigue (least likely to be treated by providers)

• Nausea/vomitting

Therapist Roles for Cancer Related Fatigue

• Assessment of fatigue’s influence of patient’s daily

• Education

• Energy conservation techniques

• Physical activity guidance

• Cognitive behavioral therapy

• Stress management and relaxation technique

• Nutritional counseling

• Social support and coping skills

• Symptom management

• Goal setting and monitoring

Chemo-Brain

Cancer treatment side effect

Clinical Manifestations of Chemo-Brain

• Changes in thinking and cognitive function (mild to severe)

  • Forgetfulness (short term memory)

  • Slower thinking

  • Difficulty concentrating

  • Periods of mental fogginess

Rehabilitation Professional’s roles for Chemo-Brain

• “Brain training” games: crosswords, matching games, puzzles etc.

• Cognitive strategies: OT and Speech therapy (routine, memory aids, & environmental modifications

• Depression and anxiety management

• Validate patient’s concerns (provide early education)

Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Removes tumors that are visible in the abdomen and uses heated chemotherapy into the abdomen to kill remaining cancer cells

What type of cancer is targeted with HIPEC?

Abdominal cancers, cancers of the appendix, colon, or stomach.

Rehabilitation professionals’ implications for HIPEC

• Preoperative Assessment and Optimization

• Postoperative rehabilitation to address weakness reduced ROM, and functional limitations

• Pain management

• Psychosocial support

• Functional restoration to improve physical function, endurance, balance, and mobility.

• Education and home management

Basic Mechanisms of Chimeric Antigen Receptor (CAR) T Cell Therapy

• Modifies T cells to recognize and attack cancer

  • T cell collection → 5 weeks for cell modification

  • Hospital admission: intensive chemotherapy (to weaken immune system to aid modified T cells

    • Modified T cells are multiplied and infused to patient

  • Remain in hospital for at least 3-4 weeks (with no complications or infections)

What types of cancer is targeted by CAR T Cell therapy?

Leukemias, lymphomas, and Multiple Myeloma

Rehabilitation professionals’ implications for CAR T Cell therapy?

• Psychological support

• Symptom management (pain/fatigue/nausea management)

• Family support and education

• Post-treatment transition and follow up

Basic mechanisms of the Whipple procedure

• When cancer originates in the head of the pancreas, it is removed along with the gallbladder, common bile duct, and a section of the small intestine.

• To reconstruct the digestive tract, a loop of the small intestine is connected to the pancreas, common hepatic duct, and the stomach

What types of cancer are targeted by Whipple procedure?

Pancreatic cancer, bile duct cancer, ampullary cancer

Cytokine Release Syndrome (CRS)

• Caused by a large, rapid release of cytokines into the blood from immune cells affected by immunotherapy

When does CRS occur?

Within the 1st week of CAR-T cells

Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) presents after what?

CRS

When does ICANS resolve?

Within 28 days

Which has a short duration, CRS or ICANS?

CRS

Signs and symptoms of CRS?

• Fever

• Hypotension

• Hypoxia

• Organ failure

Signs and symptoms of ICANS?

• Delirium, confusion, disoriented, decrease level of consciousness

• Tremor

• Ataxia

• Headache

• Aphasia (mimics stroke)

• Seizure

• Coma

Rehabilitation roles for CRS?

• Assessment of functional impairments

• Development of rehabilitation plans

• Mobility training

• ADL training

• SLP therapy

• Psychosocial support

• Coordination of care

Rehabilitation roles for ICANS?

• Functional assessment

• Development of rehabilitation plans

• Mobility training

• ADL training

• Cognitive rehabilitation

• SLP therapy

• Psychosocial support

• Coordination of care