Download Understanding Ots Unique Role in the Oncology Population

Understanding OT’s
Unique Role in the
Oncology
Population
Sarah J. Weber, MOTR/L
Vinnie Quan, MOTR/L
Overview
• Introduction
• Cancer overview
• Cancer symptoms and treatments
• OT interventions for people with cancer
Work setting
Our Cancer Care
• Initial diagnosis/Prevention through end of life
care
• Interdisciplinary approach
• Client Centered and Holistic
• Goals may change across continuum
• Affiliated care
• Fred Hutchinson Research
• Seattle Cancer Care Alliance
• Children’s Hospital
Cancer Diagnosis
• Disease in which abnormal cells divide without
control and are able to invade other tissues
• Can spread through blood, and lymph systems
• Benign vs. malignant
• Metastasis- spread of cancer from one part of
body to another
• Reference: National Cancer Institute: cancer.gov
http://www.cancer.gov/cancertopics/cancerlibrary/what-is-cancer
(Image from Understanding Cancer Series: Cancer.)
Cancer Facts
• > 100 types of cancer (mostly named for
organ/type of cell where it started)
• Main Categories:
• Carcinoma- skin or tissue that lines/ covers internal
organs
• Sarcoma- bone, cartilage, fat, muscle, or other
connective/ supportive tissue
• Leukemia- blood forming tissue (e.g. bone marrow)
• Lymphoma and myeloma- cells of immune system
• Central nervous system cancers- tissues of brain and
spinal cord
• Reference: National Cancer Institute
Cancer Statistics
• Estimated new cases and deaths from cancer in
the US in 2014:
• 1,665,540
• Deaths: 585,720
• Risk increases with age (55+)
• 1 in 2 men
• 1 in 3 women
Reference: American Cancer Society
Cancer Type
Estimated
New Cases
Estimated
Deaths
Bladder
74,690
15,580
Breast (female-male)
232,670-2,360
40,000-430
Colon/Rectal
136,830
50,310
Edometrial
52,630
8,590
Kidney Cancer
63,920
13,860
Leukemia
52,380
24,090
Lung
224,210
159,260
Melanoma
76,100
9,710
Non-Hodgkin Lymphoma
70,800
18,990
Pancreatic
46,420
39,590
Prostate
233,000
29,480
Thyroid
62,980
1,890
American Cancer Society: Cancer Facts and Figures 2014. Atlanta, Ga: American
Cancer Society, 2014. Also available online (PDF - 1.76 MB). Last accessed March 20, 2014
.
TMN Staging:
International Notation
• TNM (stages 1-4)
• Primary tumor size (T1-T4)
• To= no evidence of tumor
• Lymph node involvement (N0-N3)
• Extent of mets (M0-M1)
• Curative vs. palliative treatment
• OT approach: restorative vs. compensatory
•
http://www.bioscience.org/atlases/tumpath/index.htm (Tumor Atlas with TNM Staging for all Cancers)
Stages of Tumors
• Stage 0 (To)–Pre-invasive
• Stage 1 (T1)- Limited to organ of origin
• Stage 2 (T2)- same anatomical region (may
spread)
• Stage 3 (T3)- Spread to area around primary
organ (metastatic spread)
• Stage 4 (T4)- Metastasis to distant sites
Tumor Classification
“Grading”
• “Based on histological properties, microscopic
appearance, how FAST the tumor is growing”
• Labs looks at tumor markers: protein in blood
that is released by cancer cells which predict
trends
• 4 Tiers: Grade I, II, III, IV
Surgical Treatment for
Cancer
• Goal: Debulking- remove part of malignant tumor
to enhance effectiveness of chemo/radiation
treatment
• TAH/BSO (total abdominal hysterectomy/ bilateral
salpingo-oophorectomy) for ovarian/uterine cancer
• Removal of uterus, ovaries, and fallopian tubes
• Cystectomy and creation of ilieal conduit for
diversion of urine to urostomy
• Nephrectomy
• Prostatectomy
• Mastectomy/lumpectomy
Surgical Precautions
• Abdominal Incision- log roll, no lifting > 5-10lbs,
avoid strain, check for binder, no soaking
incision, avoid bending (use taylor sit for LB
dress), back protection/ good body mechanics
• Total pelvic exenteration: no sitting
precautions
Considerations for
Treatment
• Drains and Lines- be aware prior to mobilizing
and secure appropriately, use lanyard around
neck to secure drains in shower, cover entry to
body with glad press n seal
• Check orthostatics first time OOB, especially
with epidural in place!
• Lower body strength for transfers
• Urostomy care during showers
Cancer Treatments
• Radiation
• Chemotherapy
• Hormone Therapy
• Trials: new drugs
• Gamma ray treatment (brain tumor)
• Various transfusion (for myelosuppression)
• Platelets (thrombocytopaenia)
• Blood (anemia)
CHEMOTHERAPY
Stem Cell/Bone Marrow
Transplant
• Procedure to weaken/destroy tissues or cells that
cause blood or immune diseases and then reset or
replace those tissues or cells to restore healthy
function
•
•
•
•
•
Collect
Process to purify
Freeze
Thaw
Re-infuse after treatment
• Side effect: Graph vs. Host Disease (GVHD)- closer
the match, the less likely to get it
Types of stem cell
transplants
• Autologous- own cells
• Syngeneic- identical twin
• Allogeneic- close match
General Precautions
• Infection Control
(neutropenia)
• Sign in (clear of
airborne/infectious
illness)
• Patients can’t go off
floor if
immunosuppressed
unless cleared by
medical team and
need N95 mask
General Precautions
•Multiple Myeloma
•Check radiology (plain
films, bone scans, and
MRI’s for lytic lesions
and pathologic
fractures)
•Verify weight bearing
status or consult ortho
General Precautions
Pancytopenia (Blood
count)
• Check platelets
(thrombocytopenia)
, HCT, and Hb daily
• Avoid MMT if
platelets below 20k
Exercise and Blood Value
Precautions
• Platelet Count 50,000-100,000: cardiovascular exercise and strength
training w/ weights are allowed, no exercise if signs of bleeding
• Platelet Count 20,000-49,000: strength and cardio exercise are ok if
no signs of bleeding, but w/out strain, massage may be
contraindicated
• Platelet Count 10,000-19,000: AROM and cardio without strain are ok
if you are steady on feet and have no signs of bleeding (No PROM)
• Less than 10,000: no exercise, walking in room or to bathroom is ok
as long as you are steady and have no signs of bleeding
• Less than 5,000: May be bedrest
Exercise and Blood
Values (continued)
• Hematocrit (Hct): must be greater than 25% for
any form of exercise
• > 25 light exercise, shower
• 30-32 resistive exercise as tolerated
• Hemoglobin (Hb): greater than 8.5 for any form
of exercise
• 8-10 light exercise
• > 10 resistive exercise
Neutropenic Precautions
• Bathe daily
• Frequent gentle oral care with soft toothbrush
• Avoid anything with dirt (bacteria), live plants/ flowers
• Avoid garden work
• Don’t clean kitty litter, bird cages, or fish tanks
• Caution with dental work
• Do not use hot tubs, swim in lakes, ponds, rivers
• Neutropenic diet- fresh fruits/ veggies- raw or uncooked/
unpasteurized
•
Reference: Hope Cancer Clinic Patient Education
Precautions (continued)
• Mucositis- reddening
and soreness of tongue,
lips, mouth, throat,
and GI tract from chemo or XRT
• Keep HOB > 30*
• Aspiration risk
• Oral care
• Steroid Myopathy- progressive
weakening of proximal > distal
musculature from high
dose of corticosteroids
• Hand to foot syndrome
Soft tissue fibrosis
Use caution with gait belt placement
Other considerations
• Pain
• Fatigue
• Nausea/vomiting
• Edema/ lymphedema
• Deep Vein Thrombosis (DVT)
• Tremors (caused by transplant
meds)
• Avascular necrosis
• Fever (> 100.5)
• Deconditoning
• Psychosocial implications
• Peripheral neuropathy- chemo
induced (CIPN)
• Heart Damage: Cardiotoxicity
• Paraplegia/quadreplegia
• “Chemo brain”
•
•
Assess cognition in context
May resolve in 6-9 mo. (Anies & Saykin, 2002)
OT’s Role
• Role of OT in oncology is “to facilitate and enable an
individual patient to achieve maximum functional
performance, both physically and psychologically, in
everyday living skills regardless of his or her life
expectancy”
• Health is supported and maintained by participation
in desired roles and activities
• “87% of oncology patients have rehab needs”
• Penfold, S. (1996). The role of the occupational therapist in oncology. Cancer
Treatment Reviews, 22, 75-81.
Cancer Rehab Paradigms
• Preventative: preoperative education and training,
improve general health and function
• Restorative: Return to PLOF, change client variables,
restore skills
• Supportive: modify, prevent, maintain in natural
setting, accommodate training for existing disabilities,
minimize potential debilitating changes
• Palliative: best QOL for pt and family, balance
between function and comfort, maintain and modify
Assessments
• Pain Scale/ Visual Analogue
• McGill Pain Short Form, DASH Questionnaire,
Shoulder Pain and Disability Index
• MOCA
• KELs
• COPM
Considerations for
Treatment
• Functional status may fluctuate!!
•
•
•
•
Treatment continuum
Progression of disease
Relapse vs. remission
Modify treatment plan
• Energy Conservation/ Scheduling
Strategies for
Intervention
• Education for precautions
• Involve patient in treatment to give sense of
control and develop meaningful goals
• Individualized treatment plan
• Consider family/caregivers’ needs
• Look at restoring meaningful life roles
Interventions
• Therapeutic Exercise
• Caregiver Training
• Establish routines (written schedules)
• Therapeutic Activities
• Engage in meaningful activities (typing, crafts)
• Energy Conservation and Work simplification
training
• Make interactive and individualized for carryover
Interventions
• Fall prevention education
• Peripheral Neuropathy- review strategies for body
awareness and use of visual feedback for body
positioning
• Sensory retraining/ desensitization
• Safety (ie. Gloves in kitchen)
• Relaxation Strategies
• Diaphragmatic breathing
• Guided imagery
• Adapted yoga
Interventions
• Cognitive Retraining
• Compensatory approach
• Lymphedema Treatment (certification)
• Equipment coordination and discharge planning
• Adaptive Equipment Training
• Modified Body Techniques/ Body Mechanics and
Transfer Training
Pain Interventions
(physical)
• Therapeutic Exercise
• Graded and purposeful activity
• Postural reeducation
• Massage and tissue mobilization
• TENS, heat, and cold*
Pain Interventions
(psychosocial)
• Distraction, engaging in activities
• Anxiety mangt/ guided imagery
• Lifestyle adjustment
• Environmental adaptation
• Educational approaches
• Identify triggers (ie. Noise, lights, temp, position,
smell)
ADL Interventions
• Shower training
• Check if cleared/ hemodynamically
stable
• Coordinate with nursing and PT
• Adaptive equipment
• Bath seat, long sponge, grab bars
• Energy Conservation/ work
simplification
• Caution with shaving (electric razor)
• Care of lines/ drains
ADL Interventions
• Dressing
• Energy conservation/ work simplification
• Positioning (bed level vs. chair or edge of
bed)
• Assess for AE
• Shoe horn, reacher, elastic laces, sock
aide
• Be creative and make adaptations as
needed!
• Toileting
•
•
•
•
Assess toilet height to avoid strain
May need padding
AE: Toilet aide
*may have chemo precautions
Transitions
• Hospice
• Inpatient Rehab
• Home with family support
• Home Health
• Outpatient
• Pete Gross or SCCA House
Other considerations
• Therapist self care to prevent “burnout”
• “Tea for the Soul” for staff
• “Light the Candle”
(virtual candle +message)
• “It gave him the confidence that he could do more
for himself” – pt’s wife of his experience in
inpatient rehab
• “It’s so overwhelming. I’ve lost my strength, I feel
like I’ve abandoned my daughter. I wasn’t
expecting this at 39. You’ve been a blessing.”woman with AML in rehab
• “I always look forward to OT and PT because it
gave me hope. I aim to be able to do things for
myself again.”-Man who had relapsed after stem
cell transplant was in acute care.
Question and Answers
OT glasses
References
Arnadottir, G. (1990). The brain and behavior: Assessing cortical dysfunction through
activities of daily living. Philadelphia: Mosby.
Ahles T. A. and Saykin A. J. (2002). Breast cancer chemotherapy-related cognitive
dysfunction. Clin. Breast Cancer 3, 84-90.
Ballard-Barbash, R., George, S. M., Alfano, C. M. , & Schmitz, K. (2013, June 15).
Survivorship, Integrative Oncology from
http://www.cancernetwork.com/survivorship/physical-activity-across-cancercontinuum#sthash.dYERHZdK.dpuf
Brown, C. G. (2010) A guide to oncology symptom management. 11, 215-217.
Cambell, C., Hughes, J., & Munoz, L (2012) Occupational Therapy’s Unique
Contributions to Cancer Rehabilitation . AOTA course continuing education.
Cooper, J., and Littlechild, B., (2004, July). A study of occupational therapy
intervention in oncology and palliative care. Journal of Therapy & Rehabilitation.
11(7) 329-333
.
References
Crannell, C. and Stone, E. (2008) Bedside Physical Therapy Project to prevent deconditionning in
hospitalized patients with Cancer. OCN Oncology Nursing Forum. 35(3), 344-345.
Health condition tube (2014, April) https://www.youtube.com/watch?v=izQk051qg8M
Naik, H (2007). Some helpful hints during chemo therapy. PDF retrieved on October 1, 2014, from
http://www.hopecancerclinic.net/patient_education.
National Cancer Institute [http://cancer.gov].
Penfold, S. L. (1996) The role of the occupational therapist in ocology. Cancer Treatment Reviews , 22, 7581.
Scott Hamilton Care Initiative. Low blood counts http://chemocare.com/chemotherapy/side-effects/lowblood-counts.aspx#.VDY5nlLn_ug
Seattle Cancer Care Alliance. Exercise precautions for low blood values.
http://www.seattlecca.org/diseases/thrombocytosis.cfm
Serra, D., Parris C. R., Carper, E., Homel, P., Fleishman, S. B., Harrison, L. B., et al. (2012, December).
Outcomes of guided imagery in patients receiving radiation therapy for breast cancer. Clinical
Journal of Oncology Nursing,16 (6), 617-623.