Oncology and Edema/Lymphedema

Cancer

uncontrolled growth abnormal cells in the body

can start almost anywhere in the human body

can travel to other organs and tissues via circulatory or lymphatic system

Cancer Causes

genetic changes: oncogenes, inherited, environmental exposures (radiation, smoke, sun)

proto-ocogenes: mutate and become cancer causing

tumor suppressor genes (anti-oncogene): cells can divide in uncontrolled manner

DNA repair genes: compromised in fixing damage DNA and develop additional mutations in other genes

Normal Cells

cells grow and divide to form new cells as the body needs then

ability to differentiate and specialize

when old or damage they die

new cells take their place

Cancer Cells

cells mutate and body is unable to catch it: ability to split/grow and mutate rapidly and aggressively

take up resources, but lose ability to differentiate/specialize

often able to evade the immune system

can travel to other sites

evade apoptosis

Intrinsic Risk Factors

unable to modify or prevent

age

heredity 

immune suste competence  

metabolic abnormalities 

Extrinsic Risk Factors

modifiable, preventable 

contributors to most cancers 

environment: ionizing radiation, solar radiation, air pollution, chemicals, irritants, viruses and infections

occupation: leather and wood workers (dust), minors (coal dust), tire plant workers (carbon black), farm workers (pesticides)

lifestyle: alcohol intake, sun bathing/tanning, use of tobacco products, sexual practices, hormonal drugs, obesity and inactivity, dietary choices 

Carcinomas

begin in skin or tissues that line the internal organs

Sarcomas

develop in bone, cartilage, fat, muscles, other connective tissue

Leukemia

begins in the blood forming tissue and bone marrow

Lymphoma

beings in the glass and nodes of the immune system

Myeloma

begins in plasma cells of bone marrow

Central Nervous System Cancers

brain and spinal cord tumors

Oncologic Diseases

systems related to tumors and cancers

head and neck, thorax, digestive system, breast, genitourinary, gynecologic, musculoskeletal, skin, etc

treatment: chemo, radiation, biotherapy, surgery

Hematologic Diseases 

diseases related to the blood

leukemia, lymphoma, myeloma, bone marrow failure syndromes, myelodysplastic syndromes, myeloproliferative neoplasms

treatment: chemo, radiation, biotherapy, bone marrow transplant

Metastasis

cancel cells travel to different locations in the body 

can spread to neighboring tissue, penetrate blood vessels/system and lymphatic system then invade distant tissues/organs 

common areas: lungs, liver, bone, brain 

Symptoms of Cancer

change in bowel or bladder habits

sore throat that does not heal 

unusual bleeding or discharge

thickening or lump in breast or elsewhere

indigestion or difficulty swallowing 

obvious change in a wart or mole

nagging cough or hoarseness 

Diagnosis

symptom or screening tests with possible indication of cancer

family history

physical exam

lab tests

imaging procedures 

biopsy: needle, endoscope, surgery (incisional or excisional)

Goals of Medical Treatment

cure

prophylaxis 

control

palliation 

Chemotherapy

using chemicals to kill cancer cells

Radiation Therapy

using x-rays to kill cancer cells

Side Effects of Treatment

depression/anxiety

skin reactions

pain

nausea and vomiting

diarrhea 

swelling

cognitive changes

neuropathy 

alopecia (hair loss)

Barriers and Precautions

extended length of stay

precautions: protective isolation, chemotherapy, mobility 

stress of the medical environment 

social isolation

depression and anxiety 

communication changes

OT Role

to facilitate and enable an individual patient to achieve maximum functional performance, both physically and psychologically, in everyday living skills regardless of their life expectancy

OT Treatment Considerations

functional needs: maximizing independence, prior level of function or maintaining function, community integration/iADLs

psychosocial needs: coping snd stress management, engagement, sleep hygiene, fatigue management

medical status

sensitivity to situations

caregiver involvement

adjusting goals and plans: effectiveness of cancer treatment, prognosis, modifying environment

discharge recommendations: DME, precautions

Evaluation

standard OT evaluation with emphasis on roles, routines, psychological assessment

Intervention

participation in ADLs: adaptations to activity, environment or adaptive equipment

lifestyle management: psychosocial education for coping

sleep and fatigue management: energy conservation 

cognitive strategies: memory and executive functioning 

therapeutic exercise: ROM and positioning 

lymphedema: reduce swelling to increase participation in occupations

Coping and Managing Stress

relaxation

exercise

adapting the environment 

engagement in activités 

positive experiences 

activity as means of distraction 

Edema

palpable swelling produced by expansion of the interstitial fluid volume

when massive and generalized the excess fluid accumulation is called anasarca 

can affect any part of the body: mostly hands, arms, lets, feet, ankles 

can be the result of medication, surgery, mobility or an underlying disease (often congestive heart failure, kidney disease, or cirrhosis of the liver 

Lymphedema

a progressive chronic condition characterized by abnormal accumulation of interstitial fluid and fibroadipose tissues resulting from injury, infection or congenital abnormality of the lymphatic system

primary or secondary classification depending on etiology and presentation

Causes of Edema

pulmonary: left heart failure

peripheral: heart failure (heart pump the moves.pumps fluid), renal disease and nephritic syndrome (unable to filter fluid and produce urine; heavy loss of protein un urine output, retains salts in body to increase fluid volume) hepatic disease (liver failure → scarring/cirrhosis → ascites/fluid accumulation in peritoneal cavity), vascular (venous valves improper functioning → chronic venous insufficiency)

surgery/trauma: fluid rushes to the area to help with healing, vessels of transport or processing damaged or removed during surgery (must wait for collateral pathways to form

medications: blood pressure medications (vasodilators), thiazolidinediones (anti diabetic agent), NSAISs

pregnancy: increased retention of fluid, pressure on pelvic veins and IVC from growing uterus decreases return of blood, preeclampsia (sudden and rapid weight gain: more than 5 pounds per week, facial edema) 

immobility: decreased muscle pump action

idiopathic 

Edema Can Result In

cancer involving organs responsible for processing fluid

surgery: removal of lymph nodes and/or damage to lymph vessels

cancer spread to lymph noes or tumor blocking lymph drainage

some chemotherapy drugs → cause fluid retention

radiation therapy: damage to lymphatic system, radiation fibrosis, general inflammation/edema

Edema: Medical Management

depending on underlying etiology

cardiac: medications, surgery 

renal: medications, dialysis 

hepatics: procedures, dialysis 

vascular: medications, surgery 

surgery/trauma: medications, ice, repair of trauma

medications: alter medications if possible

Edema: Safety Considerations

edema is often a symptom of a more serious issue

need medical treatments to address underlying issue/cause 

need to provide therapy recommendations with caution: traditional treatment methods for lymphedema were designed for chronic lymphedema, not acute edema or medically related edema. contradictions to consider!

Keck OT modify treatment based on sound understanding of anatomy, physiology and case analyses to provide safe treatments that will not harm patients 

cardiopulmonary: heart conditions (CM, CHF, Valve Disease; can overload the heart and dance the patient’s heart failure); pulmonary edema (often result of fluid overload and/or heart failure; can increase fluid in the lungs if left ventricle compromised); blood pressure (can cause lard fluid shifts, which can increase blood volume towards the central system 

vascular issues: adequate arterial flow pulses; perfusion injuries can cause deep tissue thrombus injuries if compression is applied

renal issues: are the kidneys functioning? can they process fluid for excretion? 

fluid balance: I/O; how much fluid is patient retaining? does the patient have an outlet for waste fluid? 

skin integrity: can facilitate wound healing; treatment with intact skin can prevent infection, considerations (infection present: compression at acute onset of infection can spread it; compression garments or improper treatment of facile skin may cause tears or further damage)

pressure ulcers: does paint have very bony prominences? does the patient have adequate arterial blood flow to nourished area (pulse present?)?

deep vein thrombosis (DVT): can dislodge cat and cause pulmonary embolism; considerations (history of DVTs, anticoagulation, IVC filter)

CVA/Hemiplegia: lack of muscle pump action; acute (best to initiate neuro facilitation; compression can decrease normal sensory experiences and add resistance making it difficult for patient to perform any small amount of AROM they may have); chronic (decreased ability to preform A/AROM)

impaired sensation and/or cognition: concern for skin integrity

clotting factors: platelets (low values; higher risk of bruising); PT/PPT/INR (high values; higher risk of bruising and bleeding)

change in medical status: new or unknown diagnoses; be conservative; recommend patient see physician to address underlying medical issues first

OT Assessment

presentation: unilateral, bilateral generalized vs localized

texture: pitting vs non pitting/brawny, fibrotic, firm vs soft (adipose?)

skin: taught, shiny, color (“angry” red; hemosiderin staining; bruising)

temperature: warm or cold 

edema status: min/mod/max/severe, pitting

Edema: Treatment Goals

movement: increase ROM for increased functional use

skin health and integrity: facilitate wound healing, prevent infection

pain management: decreased pain/discomfort/hypersensitivity due to taut skin or crushed nerves or structures

blood pressure management: maintain or increase intravascular volume and BP

General Treatment Approaches: Edema

self monitoring and self management: parent taught to monitor own edema/lymphedema; self management (diet, exercise, environment) and self advocacy

positioning: elevating extremities (above heart if possible) or at least away from gravity (any and all parts including BE, BLE, scrotum, head/neck)

skin and nail care: monitor and assess skin; avoid infection/injury (clean, moisturize, protect skin); there is higher risk of infection with edema; decreased nutrients to skin = more difficult with wound healing; clean and moisturize (soap, water, scent free lotion)

breathing exercises and therapeutic exercise (aerobic, resistive): promote fluid draining by increasing muscle pump action; diaphragmatic breathing; wear compression garment during exercise; diaphragm stroked thoracic ducts; negative pressure created during inhalation → decreases intrathoracic pressure, increases venous and lymphatic return 

Specialty Treatment Approaches: Compression Bandaging

pressure determined by tension in the fabric, the radius of curvature of the limb and the number of layers applied 

long stretch: orthopedics

short stretch: lymphedema and other related conditions

multilayer compression system with would contact layer: venous ulcer management

Lymphatic System: Functional System 

lymph vessels (collectors)

lymph nodes 

spleen

thymus

tonsils

lymphocytes

peyer’s patches

Lymphatic System: Function 

return protein and water from interstitium to cardiovascular system

absorbs protein, fat and fat soluble vitamins (chyle) throughout intestinal lymph vessels

recognizes and responds to foreign cells, microbes and cancer cells (serves important immunological functions)

Stages of Lymphedema

latency stage (stage 0)

stage 1 (reversible)

stage 2 (spontaneously irreversible)

stage 3 (lymphostatic elephantiasis)

Latency Stage (Stage 0)

no swelling

reduced trasport capacity

“normal” tissue consistency 

Stage 1 (Reversible)

edema is soft (pitting)

no secondary tissue changes

elevation reduces swelling

Stage 2 (Spontaneously Irreversible)

lymphostatic fibrosis

hardening of the tissue (no pitting)

stemmer sign positive 

frequent infections

Stage 3 (Lymphostatic Elephantiasis)

extreme increase in volume and tissue texture with typical skin changes

stemmer sign positive

Side Effects of Edema/Lymphedema

loss of normal sensation in the affected limb

skin changes including color, texture, and temperature

higher risk of infection

weight of affects limb

feelings of fullness or heaviness

Psychosocial Implications of Edema/Lymphedema

loss of confidence

psychological distress

limitations on functioning within daily routines 

altered wardrobe 

decreased physical activity 

poor body image 

sexuality concerns 

social anxiety and avoidance 

economic concerns 

time management

Contraindication for Lymphedema Management

acute infection

acute CHF

acute DVT

aortic aneurysm 

manual lymph draining in active malignancy (relative)

Phase 1: Intensive Phase

manual lymphatic drainage: light skin stretching massage that helps promote the movement of lymphatic fluid out of the swollen limb 

not indicated for inpatient

meticulous skin care/wound care

compression bandaging 

decongestive exercise techniques 

Phase 2: Maintenance Phase

continue home program

compression garments 

check every 6 months 

return to previous function