Cancer Rehab: helping Cancer Rehab: helping patients reach optimum patients reach optimum function function Karen P. Barr, MDKaren P. Barr, MDAssociate ProfessorAssociate ProfessorRehabilitation MedicineRehabilitation MedicineUniversity of WashingtonUniversity of Washington

That leads to a lot of That leads to a lot of questionsquestions

What is Optimum What is Optimum function?function?

What is optimum What is optimum function?function?

Doing the things you want to do, the Doing the things you want to do, the best that you canbest that you can

What is a rehab doctorWhat is a rehab doctor

Four years of residency after medical Four years of residency after medical schoolschool

Also known as PM&R or Also known as PM&R or physiatryphysiatry

Many do additional fellowships and Many do additional fellowships and additional boards: pain, sports additional boards: pain, sports medicine, pediatrics, spinal cord injury, medicine, pediatrics, spinal cord injury, brain injury, and palliative carebrain injury, and palliative care

Very broad term that can encompass Very broad term that can encompass many componentsmany components

Cancer prevention (through promotion Cancer prevention (through promotion of exercise and weight loss)of exercise and weight loss)

Enhancing cancer patients function Enhancing cancer patients function and tolerance of treatments, from and tolerance of treatments, from early early txtx to palliative careto palliative care

All phases of cancer survivorship from All phases of cancer survivorship from early to preventionearly to prevention

What do you do for What do you do for cancer rehab??cancer rehab??

What do rehab doctors What do rehab doctors do?do?

Expert in diagnosis and treatment of Expert in diagnosis and treatment of musculoskeletal and neurological problemsmusculoskeletal and neurological problems

Treatment options: prescribe therapies, Treatment options: prescribe therapies, prescribe medications, prescribe medical prescribe medications, prescribe medical equipment, orthotics, and prosthetics, Do equipment, orthotics, and prosthetics, Do injections, educate, team leaderinjections, educate, team leader

How rehab doctors thinkHow rehab doctors think

““add life to yearsadd life to years””

““our organ is the systems that move our organ is the systems that move your bodyyour body””

Focus on functionFocus on function

Individualized treatment programs Individualized treatment programs based on individual goalsbased on individual goals

Be comfortable with uncertainty, Be comfortable with uncertainty, imperfection, and small victoriesimperfection, and small victories

Rehab doctors were the Rehab doctors were the original team medicineoriginal team medicine

What is a rehab teamWhat is a rehab team

Team leader is usually the physiatristTeam leader is usually the physiatrist

RN: special area of focusRN: special area of focus

PT: physical therapyPT: physical therapy

OT: occupational therapyOT: occupational therapy

ST: speech therapy (also does ST: speech therapy (also does swallowing)swallowing)

Rehab Psychologist (PhD with Rehab Psychologist (PhD with additional training in additional training in neuropsychneuropsych and and disabilitydisability

Rehab team, continuedRehab team, continued

Social worker: expert on disability, Social worker: expert on disability, services available services available

Vocational rehab specialist: work place Vocational rehab specialist: work place and disabilityand disability

Recreation therapist: community reRecreation therapist: community re-- integration issues, adjustment to integration issues, adjustment to disabilitydisability

Where do rehab docs Where do rehab docs workwork

Inpatient units (comprehensive Inpatient units (comprehensive inptinpt rehab length usually 1rehab length usually 1--4 wks after 4 wks after hospital stay)hospital stay)

Outpatient centersOutpatient centers

Sports medicine clinicsSports medicine clinics

Pain management clinicsPain management clinics

Who can benefit from Who can benefit from seeing a rehab doctor?seeing a rehab doctor? Think functionThink function

Those who need help reaching Those who need help reaching optimum function (from running a optimum function (from running a marathon to rolling over in bed)marathon to rolling over in bed)

Those with Those with neuroneuro or orthopedic or orthopedic problems that interfere with pts life problems that interfere with pts life that are not responding to current that are not responding to current care that no surgery can fixcare that no surgery can fix

Those who have barriers to exerciseThose who have barriers to exercise

Do patients really need Do patients really need this specialized care? this specialized care? CanCan’’t any doctor do that?t any doctor do that?

How are we doing now?How are we doing now?

ChevilleCheville et al et al ““detection and treatment detection and treatment of cancer related functional problems of cancer related functional problems in an outpatient settingin an outpatient setting”” Supportive Supportive care cancer Jan 2008care cancer Jan 2008

27 item questionnaire to 227 pts 27 item questionnaire to 227 pts undergoing treatment for cancer, then undergoing treatment for cancer, then review of oncology notes to see if review of oncology notes to see if problems were mentionedproblems were mentioned

ChevilleCheville, et al, et al

72% of patients identified at least one 72% of patients identified at least one functional problem. Difficulty with functional problem. Difficulty with walking (24%) and balance problems walking (24%) and balance problems (20%) were most common functional (20%) were most common functional problemsproblems

Oncologist mentioned only 6% of the Oncologist mentioned only 6% of the functional problemsfunctional problems

More long term follow upMore long term follow up

““prevalence and treatment patterns of prevalence and treatment patterns of physical impairments in patients with physical impairments in patients with metastatic breast cancermetastatic breast cancer”” ChevilleCheville et al et al Journal of clinical oncology 2008Journal of clinical oncology 2008

AvgAvg length of time with metastatic breast length of time with metastatic breast cancer 30 monthscancer 30 months

90% of patients had impairments that could 90% of patients had impairments that could be treated by rehab methods (PT, OT, be treated by rehab methods (PT, OT, assistive devices, orthotics, etc.), but less assistive devices, orthotics, etc.), but less than a third received treatmentthan a third received treatment

How are we doing long How are we doing long term?term?

SyrjalaSyrjala K et al K et al ““ recovery of long term recovery of long term function after Hematopoietic cell function after Hematopoietic cell transplantation for leukemia and transplantation for leukemia and lymphomalymphoma”” JAMA 2004 (study done JAMA 2004 (study done here)here)

At 3At 3--5 year follow up, 20% reported 5 year follow up, 20% reported major physical limitationsmajor physical limitations

Rehab for cancer survivors: common issues

Fatigue

Living with treatment side effects: surgical, chemo, radiation

Living with side effects of tumor invasion

Anxiety about symptoms

Return to former roles

examples of a patient with examples of a patient with an outpatient rehab probleman outpatient rehab problem

A patient with leg weakness after a A patient with leg weakness after a long hospitalization long hospitalization

A patient with tingling in feet and A patient with tingling in feet and balance problems after chemotherapybalance problems after chemotherapy

A patient with tumor invasion into A patient with tumor invasion into peripheral nerves or spine with peripheral nerves or spine with residual weakness after treatmentresidual weakness after treatment

A patient with head and neck cancer A patient with head and neck cancer with shoulder pain and poor swallowwith shoulder pain and poor swallow

Prototype examplePrototype example

breast cancer survivor with shoulder breast cancer survivor with shoulder and arm painand arm pain

Approach needs to be Approach needs to be individualizedindividualized

for example, There are many cancer for example, There are many cancer and nonand non--cancer related causes of arm cancer related causes of arm and shoulder painand shoulder pain

Everyone has different goals and Everyone has different goals and willingness to commit to changewillingness to commit to change

Common principle #1: Common principle #1: specific diagnosis leads to specific diagnosis leads to specific treatmentspecific treatment

First, rule out serious and easily treatable First, rule out serious and easily treatable causescauses

A thorough history and physical exam A thorough history and physical exam (experts in musculoskeletal problems, rather (experts in musculoskeletal problems, rather than just surgical problems, also great than just surgical problems, also great neuroneuro exams)exams)

May perform diagnostic ultrasoundMay perform diagnostic ultrasound

May order an MRI or May order an MRI or xraysxrays

May perform May perform electrodiagnosticelectrodiagnostic testingtesting

Common principle #2Common principle #2 function is better than function is better than disabilitydisability

It is easier to prevent decline than get It is easier to prevent decline than get regain function ANDregain function AND

It is better to adapt than not do at allIt is better to adapt than not do at all

It is hard to get back in It is hard to get back in shapeshape

You have to start You have to start somewheresomewhere

Common principle #3Common principle #3

Need certain range of motion and strength Need certain range of motion and strength to perform activities of daily living whatever to perform activities of daily living whatever the cause of the problemsthe cause of the problems

Need more range of motion and strength if Need more range of motion and strength if interested in sports, higher level or more interested in sports, higher level or more prolonged activitiesprolonged activities

Rehab approachRehab approach

Why is there pain in the arm?Why is there pain in the arm?

What is the best treatment plan?What is the best treatment plan?

What do you want to do?What do you want to do? How can you do it the best How can you do it the best you can?you can?

outpatient rehab outpatient rehab treatmenttreatment

May order specific physical therapy planMay order specific physical therapy planMay order Occupational therapy for adaptive May order Occupational therapy for adaptive

techniquestechniquesMay order compressive garments or medical May order compressive garments or medical

equipmentequipmentMay prescribe pain medsMay prescribe pain medsMay prescribe modalities such as massage or May prescribe modalities such as massage or

acupunctureacupunctureMay perform procedure such as shoulder steroid May perform procedure such as shoulder steroid

injectioninjection

The big bag of tricksThe big bag of tricks

Take the best from fields of pain Take the best from fields of pain management, sports medicine, management, sports medicine, integrative medicine, and traditional integrative medicine, and traditional rehab techniques and apply to the rehab techniques and apply to the patient with cancerpatient with cancer

Helping patients see their Helping patients see their strengthsstrengths

What about the rest of What about the rest of this patient?this patient?

It would be rare for a patient to only It would be rare for a patient to only receive treatment for one problemreceive treatment for one problem

Is she able to exercise, both for her Is she able to exercise, both for her shoulder, and the rest of hershoulder, and the rest of her

What other rehab related problems What other rehab related problems does she have?does she have?

How is patients mood and stress?How is patients mood and stress?

Common rehab principles Common rehab principles exerciseexercise

Most appropriate exercisesMost appropriate exercises

Appropriate pacing and advancing of Appropriate pacing and advancing of exercises within medical contextexercises within medical context

Enhancing adherence to exerciseEnhancing adherence to exercise

Often works with PT, athletic trainer, Often works with PT, athletic trainer, community resourcescommunity resources

Exercise componentsExercise components

Endurance/aerobic exerciseEndurance/aerobic exercise

StrengtheningStrengthening

FlexibilityFlexibility

Coordination/balanceCoordination/balance

Exercise Exercise recommendations: recommendations: AEROBICAEROBIC

30 min of moderate activity (like 30 min of moderate activity (like walking) 5x/wk or 20 min vigorous walking) 5x/wk or 20 min vigorous activity (like jogging) 3x/wk activity (like jogging) 3x/wk

At least 10 min boutsAt least 10 min bouts

THIS IS IN ADDITION TO THIS IS IN ADDITION TO ““BEING BEING ACTIVEACTIVE””

Exercise Exercise recommendations:recommendations:

Lifting weights/resistance training at Lifting weights/resistance training at least 2least 2--3x/wk (nonconsecutive days) 3x/wk (nonconsecutive days) 1010--15 reps of 815 reps of 8--10 exercises that use 10 exercises that use the major muscle groupsthe major muscle groups

Should be moderately heavy weightsShould be moderately heavy weights

Exercise Exercise recommendationsrecommendations

Stretching at least two times a weekStretching at least two times a week

Balance training at least two times a Balance training at least two times a weekweek

Sample plan of a busy Sample plan of a busy working motherworking mother

Devote 1 hour to exercise a day (in Devote 1 hour to exercise a day (in one or two sessions) one or two sessions)

30 min of aerobic every week day30 min of aerobic every week day

On Monday, Wednesday and Friday, On Monday, Wednesday and Friday, lift lift wtswts/resistance: (lunges, squats, /resistance: (lunges, squats, calf raises, push ups, biceps, triceps, calf raises, push ups, biceps, triceps, shoulders, sit ups)shoulders, sit ups)

On Tuesday, Thursday, yoga (balance On Tuesday, Thursday, yoga (balance and stretching)and stretching)

rehabilitationrehabilitation

Work in rehab exercises to fit into this Work in rehab exercises to fit into this planplan

A PT should help you do this before A PT should help you do this before we can say that you have had we can say that you have had adequate physical therapyadequate physical therapy

Why do all this work?Why do all this work?

Evidence basis for Evidence basis for exercise in cancer exercise in cancer survivorssurvivors

Is safe and well toleratedIs safe and well tolerated

Improves quality of lifeImproves quality of life

Decreases fatigue, improves immune Decreases fatigue, improves immune system, improves physical functionsystem, improves physical function

Improves cardiovascular system and Improves cardiovascular system and strengthstrength

Prolongs independence as we ageProlongs independence as we age

Decreases death from all causesDecreases death from all causes

Common rehab principles: Common rehab principles: nutritionnutrition

Protein for muscle buildingProtein for muscle building

Vitamins for nerve protectionVitamins for nerve protection

Fruit and vegetable intake for healthFruit and vegetable intake for health

Common rehab principles: Common rehab principles: sleep and restsleep and rest

What are barriers to sleep and restWhat are barriers to sleep and rest

Depression, anxiety, pain, daytime Depression, anxiety, pain, daytime inactivity, poor sleep habitsinactivity, poor sleep habits

Enough exercise, enough restEnough exercise, enough rest

Common rehab principles: Common rehab principles: returning to a full lifereturning to a full life

Adjustment to disabilityAdjustment to disability

Return to leisure activitiesReturn to leisure activitiesReturn to workReturn to workReturn to family rolesReturn to family rolesCoping skills, stress reduction Coping skills, stress reduction

techniquestechniques

Next stepsNext steps

This sounds great, but what should I This sounds great, but what should I do next?do next?

The best coach The best coach

Pay attention to functionPay attention to function

Now look at the detailsNow look at the details

Make a listMake a list

Add exercise on the listAdd exercise on the list

Setting goalsSetting goals

DonDon’’t assume you just t assume you just have to live with ithave to live with it

Add some low lying fruitAdd some low lying fruit

Keep a progress logKeep a progress log

Get help if you need itGet help if you need it