Download Objectives © 2013 Memorial Sloan-Kettering Cancer Center, All

5/13/2013
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
The presenter has no conflict of interest to report
regarding any commercial product/manufacturer
that may be referenced during this presentation.
Objectives
• Recognize red flags in oncology & cancer rehabilitation
• Recognize contraindications/emergencies in oncology &
cancer rehabilitation
• Recognize relative contraindications/precautions in
cancer rehabilitation
– Hematologic, musculoskeletal, & neurological considerations
• Discuss special considerations related to treatment
interventions
– Effects of cancer treatments
– Modalities in cancer rehabilitation
– Psychological/psychosocial issues
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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5/13/2013
Oncology & Cancer Rehabilitation:
Red Flags
Red Flags
• Contact the Physician immediately with any new onset or
increase in symptoms1
–
–
–
–
–
–
–
–
–
–
–
–
Fever
Cardiac abnormalities
Weakness or fatigue
Leg pain or cramps
Unusual joint pain
Bruising nausea
Bruising,
Rapid weight loss
Diarrhea or vomiting
Changes in mental status
Dizziness, blurred vision
Fainting, gray or pale appearance
Night pain without a history of an injury
NCI Web site, www.cancer.gov
-National Center on Physical Activity and Disability
Red Flags
• Report to physician1:
– Marked increase in existing lymphedema or sudden
onset rapidly progressive lymphedema
– Sudden increase/change in pain symptoms
– New
N
palpable
l bl mass/lymph
/l
h node
d
– Change in continence
– Venous thromboembolic events
-National Center on Physical Activity and Disability
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Oncology & Cancer Rehabilitation:
Contraindications/Emergencies
Contraindications/Emergencies
•
•
•
•
•
•
•
Malignancy
Deep Vein Thrombosis (DVT)
Pulmonary Embolus (PE)
Malignant Pericardial Effusion
Superior Vena Cava Syndrome
Hypercalcemia
Tumor Lysis Syndrome
Malignancy
•
•
•
•
Pain, paresthesia, paralysis
Location of swelling proximally
Rapid onset of edema
History of cancer
NCI Web site, www.cancer.gov
 Rehab considerations: medical management required;
refer back to MD
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Deep Vein Thrombosis
• Clot of cellular material bound to fibrin located in the
deep veins
• Signs of DVT
– Swelling of leg or along vein in leg
– Pain or tenderness in the leg
– Increased warmth in the area of the leg
that is swollen or painful
– Red or discolored skin on the leg
– Pain with ambulation
Photo courtesy of Michael Stubbliefield, MD
 Rehab considerations: medical management required;
refer back to MD
Pulmonary Embolus
• Blood clot which obstructs the pulmonary artery/vein
–
–
–
–
Unexplained shortness of breath
Pain with deep breathing
Coughing up blood,
Rapid breathing
– Fast heart rate
NCI Web site, www.cancer.gov
• Signs of PE
 Rehab considerations: medical management required;
refer back to MD
MSKCC Guidelines for Physical, Occupational, & Lymphedema
Therapy in Patients with Venous Thromboembolism
• Lower extremity
– For patients with acute LE DVT (with or without PE) & no IVC
filter, therapy can be initiated once they are therapeutic on an
anticoagulant & have received medical clearance
– For patients with an IVC filter
filter, therapy can be initiated
immediately regardless of their anticoagulation status, as long as
medical clearance has been established
– Inpatient vs outpatient
• Inpatient: therapy can begin once INR has normalized &
therapeutic on anticoagulant
• Outpatient: medical hold until physician clearance
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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5/13/2013
MSKCC Guidelines for Physical, Occupational, & Lymphedema
Therapy in Patients with Venous Thromboembolism
• Upper Extremity
– Therapy involving UE resistance or compression is generally not
recommended until the patient has been therapeutic for at least 3
days on an anticoagulant and medical clearance has been
established
– Inpatient vs outpatient
• Inpatient: may consider ADL training supervised by a
therapist, even if pt cannot be anticoagulated
• Outpatient: medical hold until physician clearance
Malignant Pericardial Effusion
• Extra fluid inside the sac that surrounds the heart
• Cardiac tamponade  Life-threatening complication
• Associated cancers/conditions: metastatic
lung/breast melanoma
lung/breast,
melanoma, leukemia
leukemia, lymphoma,
lymphoma chemo
to chest wall
• Symptoms: dyspnea, cyanosis, anxiety → venous
distention in neck, orthopnea
 Rehab considerations: requires medical management
Superior Vena Cava Syndrome
• Blockage of SVC from tumor, swollen lymph nodes, blood clot,
etc = Emergent situation
• Associated cancers/conditions: lung, lymphoma, central venous
catheter
• Onset: facial/neck swelling, ruddy complexion, protruding eyes
• Progression: UE fullness/edema
• Late findings: cardiopulmonary, CNS, GI symptoms
Rehab considerations: requires medical management
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Hypercalcemia
• Too much calcium in the blood
• Associated cancers/conditions: lung, esophageal, head &
neck, cervical
• Can affect many organs of the body → symptoms depend on
which
hi h organs are affected
ff t d
• Common symptoms: feeling tired, trouble thinking clearly,
loss of appetite, pain, frequent urination, increased thirst,
constipation, nausea, vomiting
 Rehab considerations: requires medical management
Tumor Lysis Syndrome
• Metabolic derangement that occurs with tumor
breakdown following cytotoxic therapy
• Associated cancers: blood cancers with fast growing
tumors, acute leukemia, high grade lymphoma
• Onset: polyuria, nausea/vomiting
• Progression: muscle weakness, joint pain
• Late findings: fatigue/lethargic, cloudy urine, cardiac
arrhythmias, seizures
 Rehab considerations: requires medical management
Key Points
Rehab considerations:
– Establish patient’s baseline to detect
changes and to identify progression of
disease over course of treatment
– Monitor vital signs
– Monitor fatigue levels
– Proper hydration
– Proper medication schedule
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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Oncology & Cancer Rehabilitation:
Relative Contraindications/Precautions
Relative Contraindications/Precautions
• Hematologic considerations
• Musculoskeletal considerations
• Neurological considerations
Hematologic Considerations
NCI Web site, www.cancer.gov
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Bone Marrow Suppression
• Anemia
– Low red blood cell count
– Normal values: Female 12-16 g/dl
Male 14-18 g/dl
– Symptoms:
S
t
fatigue,
f ti
iirritability,
it bilit lilightheadedness,
hth d d
lloss
of concentration, pallor
Rehab considerations:
• Monitor lab values, vital signs (HR, RR, SaO2),fatigue levels
• Modify treatment based on fatigue level
Bone Marrow Suppression
• Thrombocytopenia
– Low platelet count
– Normal values: 200,000-400,000mm3
– Signs
g and symptoms:
y p
bruising,
g, bleeding,
g,
petechia
Rehab considerations:
• Monitor lab values
• Fall precautions
• Focus on functional mobility
Bone Marrow Suppression
• Leukopenia/Neutropenia
– Low WBC count
– Normal values: 4,000 to 10,000/mm3
– Signs
g & symptoms:
y p
frequent
q
infections, fevers,
throat/mouth sores
Rehab considerations:
• High risk for infection
• Reverse/protective isolation
• Creative treatment interventions
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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Bone Marrow Suppression Guidelines
Normal
Values/Units
No
Exercise
Light
Exercise
Regular
Exercise
Hemoglobin
Females:
Males:
12 to 16 g/dl.
14 to 18 g/dl.
<8 g/dl.
8-10 g/dl.
>10 g/dl.
White Blood
Cells
4,000 to
10,000/mm3
<500/mm3
500/mm3
>500/mm3
500/mm3
>500/mm3
500/mm3
Platelets
150,000 to
450,000/mm3
<20,000/mm3
>20,000/mm3
>50,000/mm3
2.0 to 3.0
>3.0
2.0 to 3.0
2.0 to 3.0
PT/INR
Adapted from Stubblefield M, O’Dell M. Cancer Rehabilitation: Principles and Practice..
Musculoskeletal Considerations
Photo courtesy of MSKCC Medical Graphics
Bone metastases
• Primary cancer site of
breast, prostate, lung,
kidney, thyroid commonly
metastasize to bone12
• Common locations: axial
skeleton, humerus, femur,
skull, pelvic girdle, ribs12
Image courtesy of Michael Stubblefield MD
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Bone metastases
Image courtesy of Michael Stubblefield MD
• Classification
– Osteolytic
– Osteoblastic
– Mixed
• Treatment
– Surgery
– Radiation
– Biophosphonates
Bone Metastases
BONY METASTASIS
>50% cortex involved
No exercise; touch down:
not weight bearing, use
crutches, walker; active
ROM exercise (no twisting)
Plain
Pl
i x-ray findings:
fi di
hi
high
h
risk indicated by following:
cortical lesions >2.5–3.0 cm;
>50% cortical involvement;
painful lesions;
unresponsive to radiation
25 50% cortex
25–50%
t involved
i
l d
N stretching,
No
t t hi
li
light
ht aerobic
bi
activity; partial weight
bearing; avoid
lifting/straining activity
0–25% cortex involved
Full weight bearing
DeVita VT, et al. Cancer: Principles & Practice of Oncology,7th Edition. Philadelphia, Pa.
Lippincott Williams & Wilkins, 2005
Bone metastases: Rehab Considerations
• Questions:
– Weight bearing status?
– ROM restrictions?
– Positioning
recommendations and/or
restrictions?
– Assistive devices?
• Modifications of
evaluation & treatment:
–
–
–
–
Modify MMT
Modify PROM or AROM
Avoid Resistive exercises
Avoid spinal loading with
spine mets
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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Neurological Considerations
NCI Web site, www.cancer.gov
Neurological Considerations
• Tumors may cause neural impairment by
compressing or infiltrating a13:
–
–
–
–
peripheral nerve
nerve plexus
nerve tract
nucleus within the CNS
• Cardinal signs: bowel/bladder changes, unrelenting
pain particularly at night13
• Later signs: focal sensory disturbances or weakness
in the distribution of the plexus or spinal cord
segment involved 13
Neurological Considerations
• Neuropathy
• Radiculopathy
• Cognition

• ↑ intracranial pressure
• Seizures
• Mass effect
Rehab considerations:
• Monitor sensation, proprioception, balance, coordination
• Safety awareness
• Following commands
• Avoid Valsalva maneuvers
• Spinal precautions: no excessive bending or heavy lifting
• HOB elevated to 30 degrees of higher (to prevent ↑ ICP)
• Monitor for headaches, nausea, dizziness, increased BP
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5/13/2013
Spinal Cord Compression
• Onset: local back pain, escalates while supine
• Progression: paralysis, numbness
• Late: loss of bowel/bladder control
 Rehab considerations:
• Spinal precautions
• Monitor changes in bowel/bladder control
• Assess and monitor sensations to light tough,
proprioception, balance, coordination
Photo courtesy of Stubblefield M, O’D
Dell M. Cancer Rehabilitation:
Principles and Practice. Demos Medical Publishing, Inc, 2009
• Associated cancers/conditions: metastasis to spine,
breast, lung, kidney, prostate, lymphoma, myeloma
Oncology & Cancer Rehabilitation:
Special Considerations
Special Considerations
• Treatment effects
– Chemotherapy
– Radiation
– Surgery
S
– Other
• Cancer-related fatigue
• Cancer pain
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Chemotherapy
• Late effects
• Early effects
–
–
–
–
–
–
–
–
–
–
–
–
Bone marrow suppression
Appetite loss & weight changes
Taste changes
Mucositis
Infection
Fatigue
g
Alopecia
Memory/cognitive changes
Nausea/vomiting
Diarrhea/constipation
Peripheral neuropathy
Pain
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
“Chemo Brain” or “chemo fog”
Cardiac toxicity
Central & cranial NS changes
Peripheral neuropathy
Pulmonary toxicity
Pulmonary fibrosis
Gastrointestinal toxicity
Li
Liver
D
Damage
Kidney and urinary damage
Sexual & fertility changes
Skin & nail changes
Tissue fibrosis
Alopecia
Psychosocial issues
Secondary cancer (rare)
Photo by Janita Robinson, PT
Radiation Therapy
• Late effects
• Early effects
–
–
–
–
–
–
–
–
Skin changes
Swelling
Fatigue
Hair loss in the treatment
area
Mouth problems
Nausea & vomiting
Sexual changes
Urinary & bladder changes
–
–
–
–
–
–
–
–
–
–
Radiation Fibrosis
Lymphedema
Pain
Infertility
Pneumonitis
Pulmonary fibrosis
Radiation myelitis
Myelopathy
Joint problems
Secondary cancer
Treatment Effects: Chemotherapy & Radiation
 Rehab considerations:
• Recognizing toxic effects during active treatment may
result in changing or stopping treatment
• Following treatment, it is important to be able to
recognize those side effect that may require medical
management
• Communicate with the medical team
COMMUNICATION IS KEY!!!!
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Oncological Surgery Considerations
 Rehab considerations
– Precautions/restrictions: WB, ROM, surgery specific
– Reconstruction: skin grafts, nerve grafts, tendon
transfers, flap coverage
– Bone graft donor sites
– Prosthetics & Orthotics preparation/IPOP
– Real & phantom pain
– Leg length discrepancy
– Cosmetic deformity
– Lymphedema
– Edema: post-surgical vs venous insufficiency
– Pulmonary status
– Early mobility
Oncological Surgery: Precautions
Precaution
Type of Procedure/Patient
Population
Rehab Implications
No sitting
• Total Pelvic Exenteration
• Abdominoperineal
Resection
• Sacrectomy
• Hemipelvectomy
• Surgeon/pt specific restrictions
• No sitting (typically x6 weeks)
• Sidelying<->Stand transfer
• Monitor orthostatics
• HOB typically <30 degrees
• When scooting towards HOB using
chuck, pt in side-lying to limit pressure
on surgical site
• Possible ROM restrictions
• Requires clearance for
toilet/commode
• High risk for DVT
• Clear stair negotiation w/Plastics
team
Oncological Surgery: Precautions
• Video
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Oncological Surgery:
Precautions
Precaution
Type of
Procedure/Patient
Population
Rehab Implications
Spine
• Laminectomy
• Kyphoplasty
K h l t
• Spinal Mets
• Compression fx
• Cord compression
• Log rolling
• BLT (No
(N bending,
b di
lifting,
lifti
twisting)
• May need adaptive
equipment for ADLs
• Room set-up
• No Chest PT over spine
mets/surgical site
Oncological Surgery: Precautions
Precaution
Type of Procedure/Patient
Population
Rehab Implications
Head &
Neck
• s/p any head and neck
surgery
• Mandibulectomy
• Neck dissection
• HOB elevated typically > 30°
• Keep head in neutral
• No pressure to graft sites
• No constriction around neck
• No pillows
• Check diet orders
• Dental clearance
• Bone donor graft site: WB status
Steroid Myopathy
• Side effect of steroid treatments for cancer
• Onset: insidious or rapid
• Impairments: Proximal upper & lower
extremityy weakness
 Rehab considerations/functional limitations:
•
•
•
•
Difficulty ambulating
Difficulty climbing stairs
Difficulty getting up from chair
Dyspnea
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Osteoporosis
• Many cancer treatments may result in rapid &
severe bone loss
– Iatrogenic induction of hypogonadal state13
• ↓ bone mass increases risk of falls & fractures13
Rehab considerations:
• Spinal precautions
• Weight-bearing and resistive exercises
• Proper nutrition
Bedrest
Rehab considerations
–
–
–
–
–
–
–
–
–
Deconditioning/weakness/atrophy
Muscle contractures
Osteoporosis
O th t ti h
Orthostatic
hypotension:risk
t
i
i k for
f falls
f ll
Pressure sores
Pneumonia/pulmonary status
Confusion/disorientation
Thromboembolic event
Monitor vitals prior to/during/after treatment
NCI Web site, www.cancer.gov
Cancer-Related Fatigue
• According to Vogelzang et al. patients indicated that
fatigue affected their daily lives more than pain15
• Defined by the National Comprehensive Cancer
Network as a “persistent, subjective since of tiredness
related to cancer or cancer treatment that interferes with
usual functioning.
functioning ” 20
Rehab considerations
•
•
•
•
Fatigue scale
Exercise to address decreased biologic resources
Incorporate rest breaks
Plan treatment session when patient has the most energy to
maximize treatment quality
• Energy conservation techniques/ergonomics
• Sleep and wake schedule
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5/13/2013
Cancer Pain
• Overall, pain is reported by ~50% of patient at
all stages of disease and by over 70% with
advanced neoplasms25
• Types of Pain: somatic, visceral, neuropathic
Rehab considerations:
• Pre-medication
• Pain scale
• Description/location of pain
Cancer Pain: Red Flags
• When to refer back to MD:
– Unexplained pain
– Uncontrolled pain
– Night pain
– Calf pain associated with swelling, warmth,
redness/discoloration shortness of breath
redness/discoloration,
breath, and/or
increases with ambulation
– Pain associated with
•
•
•
•
New neurologic symptoms
Mental status changes
Worsening trismus
Worsening neck extensor weakness or back pain in patients
with spine instrumentation hardware
• Fever, redness/rash in area of pain
Special (Special) Considerations
• Modalities
• Lymphedema precautions
• Psychological/Psychosocial issues
Photo by Staff at Sillerman Center for Rehabilitation
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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Therapeutic Modalities: General Contraindications
• Active malignancy
• Dyvascular tissues
• Bleeding
Bl di or h
hemorrhage
h
• Damaged or regenerating nerves
• Implants in treatment area
Therapeutic Modalities: Absolute Contraindications
• Active malignancy
– Physical agents should never be applied directly
over active tumor
– Mechanical modalities should be avoided in area
of malignancy, as tumor may cause structural
instability leading to risk for fracture
Therapeutic Modalities
 Rehab implications
– Consider each pt on an individual basis
– Does benefit to patient outweigh the risk of
increasing tumor growth?
– In acute/subacute phase of treatment,
treatment adherence
to precautions is important
– In a chronic, curative, or palliative stage there are
no rules that apply for all situations
• Emphasis on communication between all members of
the medical team
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5/13/2013
Copyright © 2013 Riancorp
.
Therapeutic Modalities
– Low Level Laser Therapy
– Electrical Stimulation/TENS
– Biofeedback
Bi f db k
– Kinesiotape
– Traction
– Moist heat
– Ice packs
Photo by Staff at Sillerman Center for Rehabilitation
• Modalities at MSKCC
Lymphedema Precautions
• Caution with creating a “tourniquet” effect (e.g. BP or drawing blood)
• Educate on good hygiene keeping skin clean & dry with hypoallergenic
soap & deodorant
• Monitor for cuts/bruises & skin integrity regularly
• Monitor skin for signs of infection (e.g. heat, redness, pain, ↑ swelling)
• Caution with having patient lift heavy objects with affected arm(s)
arm(s),
straining leg(s)
• Caution with extreme heat or cold
• Encourage elevation of affected arm/leg when to improve circulation
• Instruct AROM exercises & hand/ankle pumps to improve circulation
Psychological/Psychosocial Issues
 Up to 49% of adult cancer survivors experience clinical depression22
• Influenced by 24 :
–
–
–
–
–
–
–
Type of cancer
Severity of cancer
Age at diagnosis
Income
Education
Gender
Treatment
• Personal factors:
–
–
–
–
–
–
–
Physical capacity
Independence
Control
Self esteem/concept/image
Job roles
Life roles
Social support
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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5/13/2013
Psychological/Psychosocial Issues
Rehab implications
– Consider each patient as a unique individual & adjust
treatments accordingly
– Allow for open
p communication & expression
p
of feelings
g
– Encourage pt to problem solve and engage in goal
setting when creating patient’s plan of care
– Involve family/caregivers during treatment sessions &
throughout plan of care
– Consider referral to social work or psychology
Thank You
References
1.
2.
3.
4.
5.
6.
7.
8
8.
9.
10.
11.
12.
13.
14.
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Lippincott Williams & Wilkins, 2005
Lawrence TS, Principles of Radiation Oncology. In: Cancer: Principles and Practice of
Oncology. 8th ed, 2008.
Radbruch L. Pain in Cancer Survivors. In: Walsh: Palliative Medicine, 1st ed, 2008.
Gilchrist LS. A Framework for Assessment in Oncology Rehabilitation. Phys Ther. 2009
Drouin J, Pfalzer C. Cancer and Exercise. Website of the National Center on Health, Physical
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Stubblefield M, O’Dell M. Cancer Rehabilitation: Principles and Practice. Demos Medical
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Approach. Cancer Rehabilitation in the New Millennium 2001; 92; 988-997.
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
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16.
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Vogelzang NJ, Breitbart W, Cella D, et al. Patient, caregiver, and oncologist perceptions of canerrelated fatigue: results of a tripart assessment survey. Semin Hematol 1997; 34:4-12.
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Portenoy, RK. Cancer Pain: Epidemiology and Syndrome. Cancer: 1989; 63:2298-2307.
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Letal A, Kuter DJ. Cancer, Coagulation, and Anticoagulation. The Oncologist 1999; 4:443-449.
Mock V, Atkinson A, Barsevick A, et al. Cancer-related fatigue clinical practice guidelines to Oncology.
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RianCorp LTU-904 Laser Therapy System User Manual
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