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July 8th Comprehensive Cancer
Rehab
Chris Wilson PT, DPT, GCS
PTP 646 – Metabolic, Endocrine, and Integumentary
Condition Interventions in Practice
July 2013
Types of Cancer
Types of cancers
Cancers are named by their origin:
• carcinomas
• sarcomas
• lymphomas
• leukemias
Sarcomas
Sarcomas are cancers that arise from cells of
connective tissue, bone, muscle etc.
• osteosarcoma
• myosarcoma
• liposarcoma
• synovial sarcoma
Lymphomas
Lymphomas are cancers that arise from cells of
the lymph nodes, lymph system and the
body’s immune system
• Hodgkin's Disease
• Non-Hodgkin's lymphoma
Leukemias
Leukemias are cancers that arise from cells of
the bone marrow and blood stream.
• Acute lymphocytic leukemia
• Chronic myelocytic leukemia
Carcinoma
• Most common type of cancer
• Carcinomas arise from the cell linings of body
surfaces
• Usually involve organs
Types of carcinoma
• lung
• breast
• colon
• prostate
Lung Cancer
•
•
•
•
•
•
Second most commonly
diagnosed cancer in men
and women
Leading cause of death in
men and women
Stage 1 – 4
Usually diagnosed in more
advanced stages
Difficult to screen for
Frequently metastasizes to
the brain
Lung Cancer
Screening
Types of Lung Cancer
Prostate Cance
Prostate Cancer
• Most commonly diagnosed cancer in men
• Second leading cause of cancer deaths
Prostate Cancer Grading
• A pathologist looks for cell
abnormalities and "grades" the
tissue sample from 1 to 5.
• The sum of 2 Gleason grades is
the Gleason score.
• These scores help determine the
chances of the cancer spreading
• They range from 2, less
aggressive, to 10, a very
aggressive cancer.
• Gleason scores helps guide the
type of treatment.
Colon
Cancer
• Third most common cancer
• Third leading cause of cancer deaths
• Very effective screening
• Screening can lead to prevention
Prostate cancer surgery
Colon cancer surgery
Lung cancer surgery
Overview of “Historical” Physical
Therapy for Cancer
• Patient complains of pain, dysfunction, disability
• Doctor identifies a need for physical therapy
• Patient is scheduled for physical therapy
services
• Receives a bout of care and is commonly
discharged without follow up by P.T.
• Very little to no communication between
therapists or physicians as a patient transitions
from setting to setting
• Physical therapists often outside “routine” cancer
management model
Philosophy of Rehab
“Empower patients to maintain their own
health and commitment to healing, through
an individualized exercise and wellness
program” = PRISM
Prevention
Intervention
Sustained Wellness
PRISM
Prevention Phases
• Why Rehabilitation?
– PT/OT treats impairment, such as mm weakness,
fatigue, restricted joint motion and poor cardiac
respiratory fitness. Impartment could lead to disability
and limitations.
– PT/OT aim to decrease or prevent disabilities and
promotes safe activity, at home, work, or recreational
activities
– PT/OT promotes participation and re-integration to
society, by treating impartments and disabilities
Prevention and Wellness of the
Oncology Patient
• Primary prevention – Prevention of a disease in a
potentially susceptible population – impacting the
active pathology stage
• Secondary prevention – Decreasing the duration
and severity through intervention – impacting the
impairment and functional limitation phase
• Tertiary prevention – Decreasing the degree of
disability in those with irreversible disorders –
impacts disability
Program Model
Rehabilitation Program Flow
Screening and Consultation
• Patients scheduled for free consultation/screening
• Wilson Resource Cancer Center (Troy)  Started June 2011
–
–
–
–
–
Breast
Breast cancer surveillance program pre/post surgery
GU
Lymphedema treatment when appropriate
All other cancer diagnoses
• Rose Cancer Center (Royal Oak)  Started September 2012
– Breast
– GU
– All other cancer diagnoses
• Grosse Pointe  Started July 2012
– All types
Exercise and Wellness
• Cancer Survivorship – Exercise & Wellness
Program  Similar to Cardiac Rehab- Phase III
• SOLA or community fitness
• Home Exercise Program
• Referrals as needed for other services
–
–
–
–
Cancer Resource Centers
Local Support Groups – Org/Regional services
Integrative Medicine
American Cancer Society
Paradigm Shift of Healthcare Models
• Patient Centered Medical Home
– Increased access, quality, decreased cost
• Accountable Care Organizations
– Creating facility/physician based organization to
better coordinate management of disease
– Shared profit and risk for savings and clinical and
patient outcomes
• Managed Care Systems
– Focus on Use Management and Controlling Visits
• Integrated Medical Records
• Payment models shifting toward less visits
– copays or private pay
Oncology Rehabilitation7
• Comprehensive Oncology Rehabilitation
– Began in 1922
• Program Success
– Management Plan
– Advanced certifications
– Informed stakeholders
Management & Administrative
Structure
• Comprehensive Oncology Rehab Team
Members
• Professional Communications
• Timing of Access to Patients
• Protocol Guidelines
• Advanced Training of Personnel
• Professional resources, settings, equipment
• Reimbursement, funding, costs to patients
• Research
Advanced Education
Requirements
• Oncology and Rehabilitation
–
–
–
–
–
–
Cancer Pathology & Staging
Cancer Treatments
Evolution of side effects
Timing of education & interventions
Prevention activities
Intensity of interventions- education, manual therapy
and exercise (flexibility, strengthening, aerobic)
– Current Research
– Rehab throughout the continuum of care
Education of Stakeholders
•
•
•
•
•
Physicians
Nurse Navigators
Patients
Caregivers
Social workers, nutritionists, chaplains, OT, SLP,
radiation therapists
• Insurers
• Universities & Residency Programs
• Research
Advanced Education
Opportunities
• APTA Oncology Section
– Courses
– Upcoming Certification Examinations
• Oakland University
– Graduate Certificate in Oncology Rehabilitation
– Annual Oncology Symposium
• Deb Doherty and Jackie Drouin
Documenting progress and
justifying future care
• An important part of therapy is using
functional tools to document and validate
progression or regression of care
• We use established, evidence-based,
researched outcome measures called
functional tools to document the patient’s
progress or current status
FUNCTIONAL OUTCOME
MEASURES
•
•
•
•
Berg Balance Training
10 Meter Walk Test
Modified Borg Test
5 Times Sit to Stand
Test
• FACIT
– FACT – G
– FACT – B
– Etc…
•
•
•
•
•
Functional Reach Test
Modified Reach Test
Cognitive Assessment
Bicep Test
Fear Avoidance
Behavioral
Questionnaire
• SF-36
PT FUNCTIONAL OUTCOME
MEASURES
BALANCE ASSESSMENTS
• Provide direction in terms of strength and
areas of deficits or weakness
• Used a predictability tool
• Provide risk factor information
PT FUNCTIONAL OUTCOME
MEASURES
Berg Balance Assessment
• Determine falls for older adults
• Scored from 0-56
– High Fall Risk – 36 or lower
– Medium Fall Risk – 37 - 45
– Low Fall Risk – 45 or greater
• Helps with determining discharge disposition
and predictive validity for future falls
10 Meter Walk Test
• Gait speed assessment
– Gait speed is predictive of disability, fall risk, and
future need for ECF/Nursing Home
– Therapist uses a stopwatch to quantify duration
for a patient to ambulate 10 meters.
– The more slowly a person ambulates the higher
risk of falls, injury, and need for assistance at
home
– Predictive of future morbidity and mortality
5 Times Sit to Stand
• Measures functional lower limb muscle
strength
• Quantifying functional change of transitional
movements
• Therapist asks pt to stand up and sit down 5
times as quickly as they can
• Time the patient how long to complete test
Rate of Perceived Exertion Scale
• Rating of how tired a
person is on a 1-10
• Therapy grades the
patient on this scale to
determine intensity of
treatment
FUNCTIONAL OUTCOME
MEASURES
•
•
•
•
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COGNITIVE ASSESSMENT
Orientation
• Ability to follow
commands
Alertness/Attention
Span
• Memory
Communication
• Insight regarding
deficits
Safety Awareness
Motivation
FUNCTIONAL OUTCOME
MEASURES
COGNITIVE ASSESSMENT
Allen Leather Lacing Test
• Screening test
• Provides estimate of cognitive functioning,
information processing and ability to learn
• Assists with goal setting, treatment planning
and determining discharge location
FUNCTIONAL OUTCOME
MEASURES
FUNCTIONAL REACH
TEST
• Completed in standing
• Single-task dynamic test
that defines functional
reach as “the maximal
distance one can reach
forward beyond arm’s
length while maintaining a
fixed base of support in a
standing position”
FUNCTIONAL OUTCOME
MEASURES
FUNCTIONAL REACH TEST
• Dynamic test that measures a person’s
margin of stability during a functional task
• Predicts risk for falling in the next 6 months
FUNCTIONAL OUTCOME
MEASURES
MODIFIED REACH TEST
• Adapted for patients that are unable to stand
• Completed in sitting
FUNCTIONAL OUTCOME
MEASURES
BICEP CURL
• Test of upper body strength and endurance
• 30 seconds of repeated biceps curls
• Therapists count how many repetitions the
patient can perform in 30 seconds
Functional Assessment of Cancer
Therapy - General
Nutrition and Physical Activity5
• American Cancer Society:
• ~1/3 of the cancer deaths in US each year
due to
– poor nutrition
– physical inactivity
– excess weight
• “Maintaining a healthy body weight, being
physically active on a regular basis, and
eating a healthy diet are as important as not
using tobacco products in reducing cancer
risk.”
Exercise and Wellness Program
Overview
Acute Care
Exercise
Sessions
Research
Traditional
Therapy
(PT/OT)
Exercise &
Wellness
Program
Community
Education
PT Screening
(NEW)
Supervised
Exercise
Sessions
(NEW)
Exercise and
Wellness Program
Goal:
Empower patients
to maintain their
own health and
commitment to
healing, through an
individualized
exercise and
wellness program.
Exercise and Wellness Program
Overview
• Coordinate providers and services
through continuum of care
– Hospital-Based Cancer Resource Center
• Acute Care
• Ambulatory Care
Patient Client Distribution
Exercise and Wellness Program
High Level Process Flow
(A)
(B)
(C)
Point of Entry
to the Program
Screening
Follow Up Care
Ph
R e ysi ci
fer an
ra l
Ambulatory Patient
Entry to Program
-
WCRC / ONNs
Support Groups
Radiation Onc
Inpatient Rounding
Multi-D Clinics
Physicians
Physical Therapy
Screening
(As Outpatient in WCRC
or as Inpatient in Acute
Care Unit)
Hospital
Discharge
Acute Care Patient
Entry to Program
- Inpatient Unit
Acute Care Exercise
Program
(Inpatient Unit)
Traditional Therapy
(Physical Therapy Troy)
Supervised Exercise &
Wellness Program
(Rehab & Dialysis Center 2nd Flr)
Home Exercise
(Patient’s Home)
Individual Wellness
(Patient’s Personal Gym)
Programs for the Medically
Compromised Patient in an
Inpatient Setting
• Need therapists who are dedicated to oncology floor as
their primary practice area
• Establish a personal relationship and trust with physicians,
nurses, patients, multidisciplinary team
• Non-direct care time just as valued as direct treatment time
Common reasons for admission to
hospital
• Initial diagnosis and workup
– Variable receptiveness to P.T. but “plant the seed”
• Chemotherapy treatments
– “well visit”
• Related sequelae
– ex. UTI, sepsis, confusion, dehydration, nausea, diarrhea,
vomiting, weakness, falls
• Unrelated medical issue
– still placed on oncology floor
• Decline in status or worsening of cancer
– re-evaluate patient needs or functional status
Exercise and Wellness Program
Physical Therapy Screening
• Standing request from nurse manager and
oncology chief/champion for PT Screen
• Essentially direct access for referral to PT
services
– Order often a formality but obtained
– Medical executive order reauthorized annually
• Avoids traditional model of a patient not often
getting a PT treatment till day 3-4
• Direct communication between nurse and PT
for any possible patient needs with immediate
assessment and treatment
Exercise and Wellness Program
Physical Therapy Screening
Rounding
therapist
gets
patient list
from unit
clerk
Patient
Hospice
?
No
Is pt on
PT
schedule?
Yes
Stop
Provide
Occupational
Therapy Screening
for education/ADL
training for benefit
of caregiver
Yes
Stop
No
Inpatient
Rounding
Process Flow
Initiate Screen
Check Nurse Progress
Notes for
- ambulation in halls
- exercising
- safety
Safety
concerns?
Yes
No
Stop
Provide an exercise prescription /
recommendation for therapy
-home
-gym
-mentor exercise program
-outpatient therapy
Contraindications
to PT?
No
Recommend
evaluation for
physical therapy
Yes
Stop
Multidisciplinary Rounds
• Attendees
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Oncologist
Staff nurse
Nurse manager
PT/OT
Pharmacist
Social Work
Nurse Navigator from
Cancer Center
– Pastoral Care
– Dietary
– Care
management/discharge
planner
• Roundtable
– everyone must talk about
their insights on the case
• Approximately 6 patients
discussed
– 1 Hour total
– Twice a week
• Patients chosen by Nurse
Manager due to
complexity, medical
issues, social issues,
length of stay concerns
Oncology Daily Huddles
• Brief meeting at 11:00 -11:22 AM on days when
there are not Multi Disciplinary Rounds
– All nurses, nurse manager, PT/OT, care manager,
hospice nurses, etc.
– Other members of MultiD team welcome
• 1 minute per patient
• Nurse clarifies any daily needs or concerns that
need to be addressed
• PT outlines any issues with safety, compliance,
handoff, discharge needs
Bone Metastases and Tumors
• Breast, prostate, renal,
thyroid, and lung
carcinomas commonly
metastasize to bone5
• Osteolytic bone mets more
commonly cause long bone
fx than osteoblastic8
• Bisphosphonates are
commonly prescribed to
inhibit osteoclast mediated
bone-resorption8
• Orthopedic evaluation and
radiographic studies
• Prophylactic internal
fixation favorable outcomes
vs after pathologic fx
– If unable, radiotherapy and
NWB may be prescribed
• Bone mets should prompt
conversation with primary
oncologist
Bone Metastases/Tumors and PT
• In any cases of cancer,
• Risk Factors for Imminent
PTs should be vigilant for
Fracture:9,10
bone metastases9
– Pain
• Especially with movement
• Conservative management
– Anatomical site
of WB and resistive
• translational forces
forces/manual therapy until
• WB bones
risk of fracture of bone mets
– Size of metastasis
established
• When 50% of cortex destroyed,
• PTs can and should prompt
fx rate ~80%9
for radiographs if concern
– Cortical lesions >2.5–3.0 cm
for mets or unexplained
– Unresponsive to radiation
pain
Bone Metastases/Tumor Guidelines11
• >50% cortex involved
– No exercises
– touch down or nonweight bearing
– use crutches, walker
– active ROM exercise (no
twisting)
• 25–50% cortex
involved
–
–
–
–
No stretching
partial weight bearing
light aerobic activity
avoid lifting/straining
activity
• 0–25% cortex involved
– Full weight bearing
“Bone
metastases in
the shaft of
the humerus
of a bronchial
carcinoma
with cortical
destruction in
both planes.”
Chestradiology.net
Destruction of the right vertebral arch and the
transverse processes of L3 as well as a large
paravertebral soft tissue tumor.
• Diffuse skeletal
metastases.
• Rib metastases
on the right
side.
• Left-sided
pseudolesions
at the costochondral
transition,
which are
caused by
microfractures
in
Osteoporosis.
Blood levels and exercise6
• Platelets and
thrombocytopenia
– Normal 140,000-400,000
– 50-140k low intensity exs and
aerobic exs
– 30-50k recommend AROM
and walking unless at high fall
risk
– < 25k therapy and mobility
contraindicated
• Neutropenia – increased
infection risk
– patient should wear mask
outside of room
– PT/PTA should wear mask in
room
• Hemoglobin
–
–
–
–
♀ normal – 12-16 mg/dl
♂ normal – 14-17mg/dl
8-10mg/dl – exs intolerance
<7-8 mg/dl – bedrest unless
very close monitoring
Brain Metastases11
“Brain metastases should be included in differential diagnosis
of any cancer patient in whom new neurologic symptoms or
signs develop”
• ~8%–10% occurrence of
brain mets in adults with
CA11
• Majority of brain mets from:
– lung CA (40%–50%)
– breast CA (15%–25%)
– melanoma (5%–20%)
• Historical standard of care:
– corticosteroids
– whole brain radiation therapy
• Common symptoms of
brain mets:
–
–
–
–
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Headache
Seizures
Paralysis or focal weakness
Altered mental status
Ataxia
• PT can expect some
recovery of function if
radiation, chemo, steroids
effective
Brain mets from adenocarcinoma of
lung
Emotional and Psychological Issues
• Monitor oncology staff and therapists for emotional
overload – watch for burnout
• Mourning process and encourage sharing with
colleagues, Social Work, Pastoral Care, friends
• Family dynamics in times of stress
• At times, near the end stage of life, PT often fixated
on as “the last hope” or when PT not tolerated, as
the final catalyst to transition to hospice/palliative
care
Lessons Learned during
Implementation
• Attempted a group exercise session with inpatients
with cancer
– Limited participation, isolation issues, patients preferred
to exercise with PT alone during IP stay
– May revisit when Oncology Unit expands beyond 22 beds
• Dedicate staff and time to huddles, rounds
• Constant connection, communication and follow up
between IP and OP and SAR/Homecare
• Able to obtain dedicated exercise room in Oncology
Unit renovation due to new programs implemented
Hospice and Palliative Care
• APTA HoD RC 17-11 – Unanimous and introduced by
Michigan
• The APTA endorses the inclusion of the following concepts
in hospice and palliative care:
– Continuity of care and the active, compassionate role of PTs and
PTAs
– Rights of all individuals to have appropriate and adequate access to
PT, regardless of medical prognosis or setting
– An interdisciplinary approach, including timely and appropriate
PT/PTA involvement, especially during transitions of care or during a
physical or medical change in status
– Education of PT/PTAs and students in the concepts related to
treating an individual while in hospice and palliative care
– Appropriate and comparable coverage and payment for physical
therapy services
• Task force to develop a plan to achieve these goals
PTs Role in Hospice and Palliative
Care
• Common
misunderstandings about
PTs role in
Hospice/Palliative Care
• “Aggressive PT” and “No
PT” are not the only options
• Focus to avoid interruption
in rehabilitation care
• Even more sensitive to
patient wishes/comfort
• Shift focus to:
– quality of life
– anticipatory future disability
and equipment needs
– “bucket list” assistance
– Prevention of pressure ulcers,
contractures, immobility pain
– Family/caregiver education
and support/consultation
Ambulatory Patient Receiving
Outpatient Cancer Care
Cancer Related Fatigue
Fatigue
Fatigue is considered one of the
most common side effects of
cancer.
Cancer-related fatigue (CRF)
• A distressing persistent, subjective sense
of physical, emotional and/or cognitive
tiredness or exhaustion
• Related to cancer or cancer treatment
• Not proportional to recent activity
• Interferes with usual functioning
- NCCN 2011
Causes of Fatigue
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•
Etiology unknown
Anemia (hemoglobin < 12g/dL)
Pain
Emotional distress
Sleep disruption
Altered nutrition
Altered activity
Medical issues (thyroid, heart, infections)
Fatigue Facts
• Fatigue is the most common side effect of
cancer treatment.
• Fatigue is the most distressing side effect
• MDs and RNs tend not to focus on fatigue
• Patients tend to under report their fatigue
- ACS 2011
Fatigue Facts
• Cancer Related Fatigue is not relieved by
rest
• Reported in 70-100% of persons
undergoing CA Rx
• 30 – 50% of patients report fatigue lasting
months to years after concluding treatment.
Fatigue Facts
• CRF is grossly under-treated
Fatigue Facts
• CRF has a cognitive and physical
aspects
Fatigue Facts
Encourage your patients to make
their physicians and nurses aware of
their fatigue level!
Origin of Fatigue
• From cancer treatment
• From the cancer itself
What is expected? - Surgery
• Some mild fatigue relieved with rest lasting 23 weeks post op
What is expected? - Chemo
•
•
•
•
•
“Roller coaster fatigue”
Mild to severe fatigue
Increases with dosage
Unpredictable
Should begin to ease 4 weeks after
conclusion, but may take 3-12 months to
resolve.
What is expected? - Radiation
•
•
•
•
•
Linear fatigue
Usually begins at about 4 weeks
Increases linearly as dose increases
May peak 1 week after last dose
Should begin to ease 4 weeks after
conclusion, but may take 3-12 months to
resolve.
What is not ok
• Increased shortness of breath with minimal
exertion
• Uncontrolled pain
• Inability to control side effects from
treatments (such as nausea, vomiting,
diarrhea, or loss of appetite)
• Uncontrollable anxiety or nervousness
• Ongoing depression
Fatigue Rating Scale
0 =
1-3=
4-6=
7-10=
no fatigue
mild fatigue
moderate fatigue
severe fatigue
Treatment of Fatigue
“ Try to be as active as possible as you go
through treatment. Some patients, especially
those who have extensive disease, should be
referred to a physical therapist or to an expert
in physical medicine to help decide on a
specific exercise program.”
-NCCN 2005
NCCN CRF recommendations
•
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•
•
Fatigue should be screened, assessed, and managed according to clinical
practice guidelines.
All patients should be screened for fatigue at their initial visit, at regular
intervals during and following cancer treatment, and as clinically
indicated.
Fatigue should be recognized, evaluated, monitored, documented, and
treated promptly for all age groups, at all stages of disease, prior to,
during and following treatment.
Patients and families should be informed that management of fatigue is an
integral part of total health care.
Health care professionals experienced in fatigue evaluation and
management should be available for consultation in a timely manner.
Implementation of guidelines for fatigue management is best
accomplished by interdisciplinary teams who are able to tailor
interventions to the needs of the individual patient.
Cancer-related fatigue should be included in clinical health outcome
studies.
Rehabilitation should begin with the cancer diagnosis.
NCCN Guidelines
• Consider initiation of exercise program of
both endurance and resistance exercise
• Consider referral to rehabilitation: physical
therapy, occupational therapy
NCCN 2011
Cancer Related Fatigue
What to do?
•
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Exercise 6 days a week
Lower your expectations for the day
Pace yourself use energy conservation principles
Pay attention to energy swings and schedule
tasks during the most energetic part of the day
Take mini breaks with or without a nap
Alternate high and low physical activities
Eat a healthy diet
Reduce stress and anxiety
Go to bed 20-30 minutes earlier than your usual
time to “unwind”
Treatment of CRF
• Treat contributing factors
– Treatment of medical issues
– Nutritional support
– Distress management
– Sleep support
What the research says
• The only evidence based treatment for cancer
related fatigue is:
Exercise
What the research says
• Exercise is safe during chemo and radiation.
• Exercise is helpful to exercise during radiation and
chemotherapy.
• Exercise should be encouraged
• Exercise is under-utilized
• Exercise is safe with advanced disease.
• Exercise is recommended with palliative care and
end of life
What the research says
• Exercise is helpful in persons with cachexia
– Cancer cachexia describes a syndrome of progressive weight
loss, anorexia, and persistent erosion of host body cell mass in
response to a malignant growth.
– Although often associated with preterminal patients bearing
disseminated disease, cachexia may be present in the early
stages of tumor growth before any signs or symptoms of
malignancy.
– A decline in food intake relative to energy expenditure (which
may be increased, normal, or decreased) is the fundamental
physiologic derangement leading to cancer-associated weight
loss.
– In addition, abnormalities of host carbohydrate, protein, and fat
metabolism lead to continued mobilization and ineffective
repletion of host tissue, despite adequate nutritional support.
Two ways to Fight Fatigue
• Medications
– To fight anemia and increase red blood cells
– Consult your physician
• Exercise
– Increases red blood cells
– Increase endorphins
– Improve overall conditioning
– Consult a PT/OT
Sleeping vs. Napping
• “Normal” uninterrupted nighttime sleep is
crucial.
– If “normal” sleep is being achieved and the
patient is exercising, napping as needed is ok.
– If not, napping should be discouraged.
– Medication for improved sleep is recommended if
needed.
Exercise Cautions
•
•
•
•
•
Bone metastases
Thrombocytopenia
Anemia
Fever or active infection
Limitations secondary to metastases or
other disease
Resources
• www.cancer.gov/cancertopics/pdq/suppor
tivecare/fatigue/
• www.pfizerpro.com/.../docs/NCCNFatigu
eGuidelines.pdf
Exercise Benefits
Exercise is one factor within your
control that can make a difference
in your life.
Benefits of Exercise
• Enhances immune system
• Reduces stress, anxiety
and depression
• Stimulates production of
endorphins
• Improves heart and lung
function
• Enhances muscle strength
and endurance
• Increases flexibility
• Improves sleep
• Eases some side effects of
treatment
• Maintain steady weight
• Lowers cholesterol levels
• Strengthens bones
• Control blood sugar
• Improves leans body mass
• Lessens fatigue
• Reduces “Chemo Brain”
• Decreases constipation
• Improves quality of life
Exercise Precautions
• Avoid exercise if you:
– Have any type of infection
– Feel dizzy or unstable
– Have a fever
– Had Chemotherapy with 24 hours
– Have low blood counts
Cardiovascular Conditioning
• A form of exercise important to all cancer
patients but especially those on
Chemotherapy drugs that have cardiotoxic
side effects.
• Improves physical and mental functioning
• Prevent recurrence and extend survival
• Consult physician about any precautions
• Learn to take and track your heart rate
• 30 minutes 5 days a week
Heart Rate
•
•
•
•
Maximum Heart Rate = (MHR)
MMR = 220 – your age
Target HR (lower limit) = 0.6 x MHR
Target HR (upper limit) = 0.8 x MHR
Strength Training
• A gradual, progressive strength training program
may actually minimize the risk for lymphedema by
helping dilate or widen remaining lymphatic
channels
• Prevents deconditioning from cancer related
treatments
• Start slowly but 6 days a week
• Alternate arm, leg and core exercise doing each
group 2 times per week
• Low to moderate load for 8-10 reps.
Benefits to Strength Training
• Muscles burn calories twice as efficiently as
fat and therefore help to maintain or lose
weight
• Improve posture
• Build stronger bones
• Increase lean body mass
• Improve balance and coordination
• Use less effort to perform work and home
activities
Flexibility and Stretching
• Muscles and fascia can tighten up after
surgery, radiation and chemotherapy
• Tight muscles and fascia can cause
significant musculoskeletal problems to
joints
• Stretching improves joint motions,
decreases pain and increases circulation
Rules for Stretching
• Needs to be done in all positions…sitting,
standing, hands and knees, side lying and lying on
belly and back
• Long term effects of stretching needs to be done
daily for long term
• Should be completed after cardiovascular and
before strengthening
• Consult PT/OT for optimal exercise for your
condition
Resources
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•
•
cancer.org (American Cancer Society)
nci.gov (National Cancer Institute)
nccn.org (National Comprehensive Cancer network)
breastcancer.org
seer.cancer.gov (National Cancer Institute)
Exercise Education
• Weight loss / management is a critical part
of the long term treatment success for our
patient.
• Being too thin and too heavy is unhealthy
– Open discussion
– Describe why it is hard on the body
– Make a realistic plan for the patient
Exercise Education
• Give the patient a visual understanding
of why they need to build
cardiopulmonary and muscular strength
– “You are an athlete in training”
– “fill your pantry”
– “Manage you battery”
Exercise Guidelines
• Make sure the mode is enjoyable
• The mode needs to be doable / accessible
• Make sure the patient is successful
immediately
Exercise Guidelines
• Start aerobic exercise on first visit
• Take advantage of post – operative or inbetween treatment timeframes
Exercise Guidelines
• Should involve both aerobic and strength
exercise
• “longer” exercise is better than “faster” exercise
• Should incorporate UE, LE and Core
• Any amount of exercise is helpful
Exercise Guidelines
• Minimalist program:
• Walk 5 minutes, twice a day
• Wall pushups
• Sit to stand
Exercise Guidelines
• Goal is an average of 1 to 5 hours per week
of combined aerobic and strength exercise
• Direct correlation with the number of lymph
nodes removed and if you are to receive
radiation.
Lymphedema Triggers
•
•
•
•
•
-INFECTION
- RADIATION
- EXTREMES OF HEAT
- TIGHT CLOTHING/ BP CUFFS
- AIRPLANES FLIGHTS
Lymphedema
• results in swelling or accumulation of fluid in one or
more limb or extremity
• caused by the break down of the body's ability to
remove and filter intercellular fluids
• condition effects both men and women
• may be a side effect of treatment for cancer
• surgical removal of lymph nodes,
mastectomy/lumpectomy , radiation, trauma and
hereditary factors can cause lymphedema.
Primary Lymphedema
a. Hypoplasia- one does not have enough lymph
vessels or the vessels are too narrow to carry an
adequate load of fluid
b. Hyperplasia - the vessels are too wide and the
valves are unable to work properly preventing
effective removal of fluid.
c. Aplasia - absence of single lymph vessels or
capillaries
d. Fibrosis - nodes become hardened and
malfunction
Secondary Lymphedema
• lymph nodes or lymph
vessels damaged or removed
• may be the result of surgical
removal of nodes
• radiation therapy
• traumatic damage to large
lymph vessels or nodes
following an accident
• infections, bacteria or fungi
Malignant Lymphedema
• when a tumor/cancer is the cause of
lymphedema
Lymphedema –Usual signs and
symptoms
• Onset might be slow or rapid
• Progressive swelling
• In many cases starts distally
– Squaring of toes
– Stammer’s sign positive
– Loss of anatomical contours
• Asymmetric swelling if bilateral
• Cellulitis is very common
• Discomfort, heaviness,
achiness
• Skin changes in later stages
Diagnosis of Lymphedema
 Case history and clinical examination are
very important to determine diagnosis
• Diagnostic investigations are not generally
necessary
• Other tests to rule out other causes of edema
– Heart, kidney, liver, thyroid,
• Diagnostic investigation to exclude
malignancy, prepare for surgical treatment,
determine vascular status
Differential Diagnosis
•
•
•
•
•
•
•
•
•
•
•
Lipedema
Lipolymphedema
Post-thrombotic syndrome/DVT
Chronic Venous Insufficiency
Ruptured Baker's Cyst
Malignancy
Reflex Sympathetic Dystrophy
Congestive Heart Failure
Fluid Retention Syndromes
Immobility/dependency
Hepatic/renal disorders
Stages of Lymphedema
Latency Stage
• No visible signs of lymphedema.
• Lymph collectors are able to keep up.
• This stage, if identified early, we may be able
to prevent enlargement of a limb
Stages of Lymphedema
Stage I Reversible Lymphedema
– Accumulation of protein rich edema fluid.
– Develops after physical exertion or at the end of
the day and disappears after a nights rest.
• Clinical signs:
– Soft pitting edema
– Texture is smooth
Stages of Lymphedema
Stage II Spontaneously Irreversible Lymphedema
• Protein rich fluid with connective and scar tissue.
• Clinical signs:
– Pitting is denser
– Gooey consistency
– Texture harder because there is more protein present
• (fibrosis starts).
• Can get skin conditions such as eczema and
erysipelas, papillamatosis and lymph fistule.
Stages of Lymphedema
Stage III Lymphostatic
Elephantiasis
– Protein rich fluid
– Connective and scar
tissue
– Hardening of dermal
tissue and papillomas of
the skin
• (angiomas)
• Clinical signs:
– Extreme swelling of the
limb
– Extreme deepening of
skin folds
– Papillomas
– leg looks like a column
and arm looks like a log
– Ulceration and
lacerations are common
Management of Lymphedema
• Risk reduction, education, precautions
• Early diagnosis and treatment
• Complex Decongestive therapy –CDT
–
–
–
–
–
Manual lymph drainage
Compression bandaging
Exercise
Skin and nail care
Instruction in self care
• Compression pumps
• Surgery
Lymphedema Mgt. (Complete
Decongestive Therapy)
Manual Lymph Drainage
• Purpose of this hands on technique is to facilitate
peristalsis of the lymphangion
• Increase in peristalsis will help pump the fluid
through the lymph system at a faster rate
– increase LTV
• Reroutes the lymph flow around the blocked areas
into more centrally located healthy lymph vessels
which drain into the venous system.
Lymphedema Mgt(CDT)
Manual Lymph Drainage
• The proximal area is treated
first, clearing first the adjacent
and unaffected lymphotomes,
then the proximal sections of
the affected lymphotomes
• The direction of pressure
depends on the areas of
edema, and the direction should
always be towards a cleared
lymphotome
Lymphedema Mgt. (CDT)
Manual Lymph Drainage
• The technique and variations are repeated
rhythmically at least 10 times either in the same
location using stationary circles or in an expanding
circle
• useless to do any less because the interstitial mass
of the tissue fluid needs some time before it
responds
Lymphedema Mgt.(CDT)
Manual Lymph Drainage
• The pressure phase of a half circle lasts
longer than the relaxation phase
• As a rule there should be no reddening of the
skin(this relative)
• The technique should not elicit pain
Lymphedema Mgt.(CDT)
Compression Bandaging
• Reduces the ultrafiltration rate
• Improves the efficiency of the muscle pump
and joint pumps
• Prevents the reaccumulation of evacuated
lymph fluid
• Breaks up fibrotic tissue(scar and connective
tissue)
Lymphedema Mgt.(CDT)
Patient Education
• Patient/family instructed in
• self MLD
• self Bandaging,
• skin care precautions
• therapeutic exercises
• goal of the program is for the patient/family to be in
control of their lymphedema management
Compression
• Increases interstitial pressure, reducing
leakage of capillary and increase absorption
of tissue fluid by venous and lymphatic
vessels during ultrafiltration
• Compression from foam pieces decreases
fibrotic tissue
Compression
• Decrease capacity of superficial veins and
lymph vessels by decreasing the vessel
lumen diameter, which decreases blood
volume, improves flow rate and decreases
reverse flow
• Contraindications: Arterial occlusive
disease , cutaneous infections and dermatitis.
Compression Bandaging
High elasticity(long stretch)
• Continuous compression with low resistance,
i.e.Stockings and ACE wrap
• can be extended 100-200%
• contain high elastic components
• develop high restoring force and hence develop
high resting pressure
• should only be worn with activity and not at rest.
Compression Bandaging
Low elasticity(short stretch)
• Gives resistance and compression
• will have 30-90% extension
• restoring force is low as is their resting pressure
• When muscles are active, low stretch bandages
form a support since they create a high working
pressure
• can be worn at rest and with exercise
Contraindications to CDT
Absolute Contraindications
• Untreated malignant tumors tending toward
metastases
• Acute inflammations(bacterial or viral)
• Thrombosis
• Active TB
• Allergic reaction
Contraindications of CDT
Relative Contraindications
• Chronic inflammation
• Functional disturbances of thyroid (if treated
okay to do treatment)
• Bone marrow patients(must be cleared to be
in the community without a mask, watch for
fatigue)
Contraindications to CDT
Relative Contraindications
• Bronchial asthma (do not treat during an acute
episode)
• Cardiac arrhythmia(check with physician)
• Deep abdominal drainage is not performed
during menses, on pregnant patients or
inflammatory disorders of the abdomen
Contraindications to CDT
Contraindications to Bandaging
• Arterial diseases
• Cardiac edema
• Acute infections
• Malignant lymphedema (can do for palliative
treatment)
• Bandaging should never cause pain,
numbness/tingling, discoloration of digits. Remove
immediately if happens.
Goals of CDT
• Utilize remaining lymph vessels and other
lymphatic pathways
• Decongest swollen body parts(arm/trunk)
• Eliminate fibrotic scar tissue
• Avoid the reaccumulation of lymph fluid
• Prevent/eliminate infections Maintain normal
or near normal size of limb
• Functional return to ADL's
Materials for Compression
Skin Care
• Skin obtains nourishment from underlying
blood supply
• Swelling increases the distance between skin
and blood supply
• Increased risk for infection
Skin Care
•
•
•
•
Daily “skin checks”
Caution when cutting nails
Use wooden cuticle tools
Avoid artificial nails
Skin Care – Lotion
• Important to keep skin hydrated
• Decrease risk for skin breakdown and
infection
• PH level of lotion approximately 7.0
which is natural PH of skin
• Gentle lotion – low in alcohol
– Johnson & Johnson Baby Lotion
– Curel
– Eucerin
Extreme Hot or Cold
AVOID:
• Hot packs or
ultrasound
• Deep massage on
affected limb
• Saunas
• Hot tubs
• Sunburns
• Hot showers
Exercise and Wellness Program
Point of Entry to the Program
• Ambulatory Patient Entry
–
–
–
–
–
–
–
Cancer Center / Oncology Nurse Navigators
Local Support Groups
Radiation Oncology Department
Multi-Disciplinary Clinics
Physicians / Physician Offices
Inpatient Unit Rounding (Acute Care PT Referral)
Patient Self Referral
Exercise and Wellness Program
Physical Therapy Screening
Patient referral to
Survivorship Exercise &
Wellness Program
- 2 North IP Unit
Patient referral to
Survivorship Exercise &
Wellness Program
- Outpatient referral
Physical Therapist
receives auto referral
from oneChart
Physical Therapist
meets with patient in
inpatient room
Physical therapist
performs a screening
in WCRC
WCRC Clerical rep
receives referral for
Survivorship Exercise
& Wellness
WCRC Clerical rep
faxes referral form to
PT/OT Clerical
Coordinator
(248-964-4020)
Clerical Coordinator
contacts and
coordinates
appointment time
with patient
Referral from:
- WCRC / ONNs - Support Groups
- Radiation Onc
- Patient (Self)
- Multi-D Clinics - Physician Office
Clerical Coordinator
has patient sign
consent and waiver
(1st Floor RDC)
Clerical Coordinator
collects payment for 6
sessions ($42) in
Counterpoint, prints 2
receipt copies and gives 1
to patient (1st Floor RDC)
Clerical Coordinator
escorts patient to 2nd
floor RDC gym and
meets PTA to give
paperwork
Patient arrives and
Clerical Coordinator
checks in patient and
completes initial
registration process (1st
Floor RDC)
Physical therapist
prescibes specific
therapy based on
screening
30 minutes per patient
Tuesdays 8-11am and
Wednesdays 1-4pm
Yes
If non-responsive
after 48 hours, call
physician office
Clerical Coordinator
tracks patient
referrals in existing
tracking spreadsheet
Physical Therapy
dept obtains
physicians referral for
therapy with
signature
Physical Therapist
provides findings to
referring physician(s)
via fax, requesting
prescription for PT/OT
Physician referral
received for PT/OT
Clerical Coordinator
schedules patient for
PT/OT
Patient undergoes
PT/OT
Clerical
Coordinator
creates self pay
appointment (CA
SURV visit type)
with OP HAR
Clerical Coordinator
contacts patient,
discusses program
and schedules for
first exercise
session
Personal/family guarantor account;
Billing indicator automatically applied
to visit type to avoid use of insurance
Clerical Coordinator
deposits payment
collections and receipts in
dropbox at end of day
Linen used from 1st
floor and deposited in
soiled utility room
Physical therapist
provides patient
education
Patient signs in and
exercises in RDC 2nd
floor gym with PTA
oversight
PTA completes clinical
documentation regarding
patient activities (RODC
and chart stored in
locked file cabinet)
Physical therapist
completes
registration form and
hands/faxes to
Clerical Coordination
(248-964-4020)
Tuesdays and
Thursdays 10am-2pm
PTA tracks patient
sign in for 6 sessions
(location of sign in to
be determined)
Does patient
require one-on-one
rehabilitation with
physical therapy?
No
Physical Therapist
provides findings to
referring physician(s) via
fax, requesting clearance
for exercise program
Physical Therapist
develops
individualized
program for ongoing
fitness
Patient pays for
additional 6
sessions on 1st Flr
RDC when needed
Patient continues
attending exercise
sessions in RDC 2nd floor
gym as appropriate
Exercise and Wellness Program
Follow Up Care
• Physical Therapist will provide patient and
physician with an evaluation, a specific
exercise assessment and an exercise
prescription
• Patient will follow one of four programs:
–
–
–
–
1. Traditional Therapy (requires physician Rx)
2. Supervised Exercise & Wellness Program
3. Home Exercise
4. Individual Wellness
Exercise and Wellness Program
Follow Up Care (Continued)
Supervised Exercise & Wellness Program
– Patients are able to implement their recommended
exercise program in a Beaumont facility with skilled
supervision
• Located at the Beaumont Medical Center, Sterling Heights –
Rehabilitation and Dialysis Center
– Open exercise sessions
• Tuesdays and Thursdays from 10am to 7pm (2-4pm by request)
– Nominal fee for participation
• Self pay at $7 per session
– Shared gym space with Cardiac Rehabilitation Phase
3 and Pulmonary Rehabilitation
“To be complete, a healing system must
be able to cover the entire field of
human experiences – physically,
mentally and spiritually.”
~ Stanley Burroughs
Acknowledgements
• Reyna Colombo – Director Rehab Services,
Beaumont Troy
• Jackie Drouin – Oakland University
• Deb Doherty – Oakland University
• Kris Thompson – Oakland University
• Dr. John Maltese – Physical Medicine and
Rehabilitation – Beaumont Health System
• Dr. Adil Akhtar – Beaumont Oncology Services
• Dr. Eric Brown – Beaumont Oncology Services
Questions?
For Further Information
• Beaumont Health System
– www.beaumont.edu
• Healthcare Advisory Board
– www.advisoryboardcompany.com
• Association of Community Cancer Centers
– www.accc-cancer.org
• American Physical Therapy Association –
Oncology Section
– www.oncologypt.org
• American College of Surgeons – Commission on
Cancer
– www.facs.org/cancer
References
1.
2.
3.
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National Coalition of Cancer Survivorship. Defining Terms. Available at
http://www.canceradvocacy.org/resources/take-charge/defining-terms.html
Accessed February 20, 2012.
Association of Community Cancer Centers. Cancer Program Guidelines.
Rockville, MD: Association of Community Cancer Centers; 2009.
American College of Surgeons Commission on Cancer. Cancer Program
Standards 2012: Ensuring Patient Centered-Care. Chicago, IL. American
College of Surgeons: 2012.
Healthcare Advisory Board. Cancer survivorship. Available at
http://www.advisory.com/Research/Oncology-Roundtable. Accessed February
20, 2012.
American Cancer Society. Cancer Facts and Figures 2012. Available at
http://www.cancer.org/Research/CancerFactsFigures/index. Accessed
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Malone DJ, Bishop Lindsay KL. Physical Therapy in Acute Care: A Clinician’s
Guide. Thorofare, NJ. Slack Inc. 2006.
Stubblefield MD. Cancer Rehabilitation. Seminars in Oncology. 2011; 38: 386393.
Michaelson MD, Smith MR. Bisphosphonates for Treatment and Prevention of
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Mirels H. Metastatic disease in long bones: A proposed scoring system for
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Coleman RE. Management of Bone Metastases. The Oncologist. 2000; 5:463470.
DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles & Practice of
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Barnholtz-Sloan JS, Sloan AE, Davis FG et al. Incidence proportions of brain
metastases in patients diagnosed (1973 to 2001) in the Metropolitan Detroit
Cancer Surveillance System. J Clin Oncol 2004;22:2865–2872.
Stout NL, Pfalzer LA, Springer B, et al. Breast cancer–related lymphedema:
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Drouin JS, Wilson E, Battle E, Seidell JW et al. Changes in Energy
Expenditure, Physical Activity and Hemoglobin Measures Associated with
Fatigue Reports During Radiation Treatment for Breast Cancer: A Descriptive
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Removal of Acoustic Neuroma: A Case Report. J Neurol Phys Ther. 2010; 34:
41-49
Appendix5